Pathologists / Introduction / General Information / Staff / Map / Flow Cytometry
Histopathology / Cytopathology / Hematopathology / PLA Home Page

Administrative Support Services

Monthly Physician Billing

Direct Patient Billing

Third Party Billing

Requisition

To simplify our testing services, Pathology Laboratories of Arkansas, P.A. is now using a single requisition form for all laboratory services. Each requisition is a multi-part form allowing appropriate clinical data, patient information and insurance information to be completed.

The following information is required on the requisition in order to process the specimen and bill for the services rendered:

Patient Information Section

  • Patient name, sex, date of birth, and other relevant demographic information.

Specimen Information

  • Specimen collection date, specimen type, and the source of the specimen.
  • Provide a written diagnosis or ICD-9 code.
  • Indicate special requests and pertinent clinical history.

Billing Information

  • Indicate if the billing should be to the referring physician/clinic, to an insurance/HMO/PPO/PCN, to the patient, to Medicare or to Medicaid by checking the appropriate box.
  • If we will be billing the patient, record the patient's address, telephone number, social security number, and the responsible party's name in the billing information section.
  • If Medicare or Medicaid billing is needed, record the patient's Medicare or Medicaid number in the appropriate section. It is also necessary for Medicare patients to sign the Advance Waiver Statement. This will allow us to bill the Medicare allowable amount to the patient should the testing be considered a non-covered screening service.
  • If we are to bill the patient's insurance, record the following information for the primary and, if applicable, the secondary insurance carriers:
    • The patient's home address and telephone number.
    • The patient identification number or social security number.
    • The insurance company(ies) name(s).
    • The insurance group identification number.
    • A responsible party's name, phone number and place of employment.


Testing Requested

Indicate testing desired with notation of any special requests. Use any test name which occurs on this web site. Special requests may be listed in the area provided.

Requisition form PDF format (Needs Acrobat Reader 7.0 or higher)

Back to General Information

Copyright © 1998-2007 Pathology Laboratories of Arkansas, P.A.