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 collection date, specimen type,
and the source of the specimen.
- Provide a written diagnosis or ICD-9 code.
- Indicate special requests and pertinent
- 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
- 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
- The patient identification number or social
- The insurance company(ies) name(s).
- The insurance group identification number.
- A responsible party's name, phone number
and place of employment.
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)
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