General Health Requisition Form DLO General Health Requisition Form is easy to complete. Simply fill out the sections on patient information, test ordering, specimen coding, and billing. It is important to fill out the form accurately and completely to minimize follow-up and ensure you receive timely reports. The pages that follow explain how to complete each section in more detail. 3 Side 1 Your Practice Information Patient and Billing Information Test Ordering ACCOUNT #: NAME: ADDRESS: CITY, STATE, ZIP TELEPHONE #: DATE COLLECTED TIME TOTAL VOL/HRS. AM PM ML HR Fasting Non Fasting : MY ACCOUNT PATIENT MEDICARE RAILROAD MEDICARE MEDICAID LabCard/Select OTHER INSURANCE BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE) REGISTRATION # (IF APPLICABLE) SEX M M D D YEAR PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID # ROOM# LAB REFERENCE # PATIENT PHONE # — — — — ( ) PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY# PRIMARY INSURANCE CO. NAME MEMBER / INSURED ID# GROUP # INSURANCE ADDRESS CITY STATE ZIP EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient) CITY STATE ZIP SUFFIX STATE RELATIONSHIP TO INSURED: អ SELF អ SPOUSE អ DEPENDENT MEDICARE NUMBER DATE OF BIRTH MEDICAID NUMBER ICD9 Codes (enter all that apply) STAT DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma. QD20354M-XO. R e v i s e d 1 0 / 0 9 . PRIMARY INSURANCE TOTAL TESTS ORDERED COMMENTS, CLINICAL INFORMATION: Reflex tests are performed at an additional charge. ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE) @= May not be covered for the reported diagnosis. F = Has prescribed frequency rules for coverage. & = A test or service performed with research/experimental kit. B = Has both diagnosis and frequency-related coverage limitations. M e d i c a r e L i m i t e d C o v e r a g e T e s t s P r o v i d e s i g n e d A B N w h e n n e c e s s a r y ADDRESS: CITY: Client # OR NAME: អ Fax Results to: ( ) ZIP STATE Send Duplicate Report to: NON-PHYSICIAN PROVIDER: NAME I.D.# 800.891.2917 • www.dlolab.com NPI/UPIN ADDIT’L PHYS.: Dr. NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED) For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessary for the diagnosis and treatment of the patient. Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr Lithium S Magnesium S Microalbumin, Random Urine w/Creat Microalbumin, 24 Hour Urine, w/o Creat Phenytoin SR Phosphorus S Potassium (K) S Progesterone S Prolactin S Protein, Total (TP) S PSA, Total S Rheumatoid Factor S RPR (Monitoring) w/Reflex Titer S RPR (DX) w/Reflex Confirm S Rubella IgG S Sed Rate By Mod West L Sodium (Na) S Testosterone, Total S Triglycerides (Trig) S TSH S TSH w/Reflex T-4, Free S T-3, Total S T-3 Uptake S T-4 (Thyroxine), Total S T-4 (Thyroxine), Free S UA, Dipstick Only U UA, Dipstick w/Reflex Microscopic U UA, Complete (Dipstick & Microscopic) U UA, Complete, w/Reflex Culture Culture, Group A Strep* Culture, Group B Strep* Culture, Genital* Culture, Throat* Culture, Urine, Routine* (Inc. Indwelling Cath.) Chlamydia DNA Probe, Endocx Or M/Uret N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret Chlamydia & N. gonorrhoeae w/Reflex ID, DNA Probe, Endocx Or M/Uret OTHER TESTS HEMATOLOGY OTHER TESTS (continued) 7788 223 234 823 243 249 795 822 285 287 4420 @ 29256 ABO Group & Rh Type L Albumin (Alb) S Alkaline Phosphatase (AP) S ALT (SGPT) S Amylase S ANA w/Reflex Titer S Antibody Scr, RBC w/Reflex ID L AST (SGOT) S Bilirubin, Direct (DBili) S Bilirubin, Total (TBili) S C-Reactive Protein S CA 125 S @ 510 @ 509 @ 1759 @ 6399 B 8847 @ 763 Hemoglobin L Hematocrit L CBC (Hgb, Hct, RBC, WBC, Plt) L CBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) L PT with INR B PTT, Activated B 34392 @ 10256 10165 10231 B 7600 B 14852 20210 B 10306 303 310 F 10124 B 978 330 B 334 375 @ 418 B 8293 @ 457 @ 466 470 B 482 8477 B 484 B 483 8435 B 8396 B 608 B 496 @ 512 @ 4848 499 @ 498 @ 8472 @ 19728 @ 7573 @ 571 593 599 615 713 718 733 745 746 754 B 5363 4418 799 36126 802 809 836 873 B 896 B 899 B 36127 859 B 861 B 867 B 866 @ 6448 @ 7909 @ 5463 @ 3020 17303 17304 17305 4485 5617 4558 394 @ 395 8502 8501 6919 Calcium (Ca) S Carbon Dioxide (CO2) S Cardio CRP S CEA S Chloride (Cl) S Cholesterol, Total (TChol) S Creatinine (Cr) w/eGFR S Digoxin SR Direct LDL S Ferritin S Folic Acid S FSH S GGT S Glucose, Gest. Scr. GY Glucose, Plasma GY Glucose, Serum (Glu) S hCG, Serum, Qual S hCG, Serum, Quant S HDL S Hemoglobin A1c L Hep A Ab, IgM S Hep B Core Ab, IgM S Hep B Surface Ab Qual S Hep B Surface Ag w/Reflex Confirm S Hep C Virus Ab S HIV-1/HIV-2 Scr w/Reflexes S Iron (Tot), IBC % Sat S Iron, Total S LDH S Lead (B) TN LH S Electrolyte Panel S Hepatic Function Panel S Basic Metabolic Panel w/eGFR S Comp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) S Lipid Panel w/Reflex DLDL S Obstetric Panel w/Reflex 2L,S Hepatitis Panel, Acute w/Reflex S Source ( R e q u i r e d ) ORGAN / DISEASE PANELS Amplified Specimen Type (please check one) ❒Endocervical ❒Urethral ❒Urine Stool Pathogens Chlamydia DNA, SDA N. gonorrhoeae (GC) DNA, SDA Chlamydia & N. gonorrhoeae DNA, SDA 10045 4475 10019 30264 681 * Additional charge for ID and Susceptibilities MICROBIOLOGY Culture, Stool, Culture, Campylobacter* Culture, Salmonella/Shigella* E. coli Shiga Toxins, EIA O & P w/Permanent Stain (Campylobacter Salmonella/Shigella)* 613 @ 622 6517 4555 294 905 916 @ 7065 @ 927 17306 Urea Nitrogen (BUN) S Uric Acid S Valproic Acid SR Vitamin B12/Folic Acid S Vitamin B12 S Vitamin D, 25 Hydroxy, LC/MS/MS SR Panel Components on Back Occult Blood, Feces - FIT, InSure ®1 B 11290 DX B 11293 MCR Scr Affixed Label 000-00000 Family Practice Associates One Malcolm Ave Teterboro, NJ 07608 201-555-1234 ( ) A12345 Last Name, First Name 000-0000 123456789
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general Health requisition Form
DLO General Health Requisition Form is easy to complete. Simply fill out the sections on patient information, test ordering, specimen coding, and billing. It is important to fill out the form accurately and completely to minimize follow-up and ensure you receive timely reports. The pages that follow explain how to complete each section in more detail.
3
Side 1
Your Practice
Information
Patient and Billing Information
test Ordering
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ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
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IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573
@ 571593599615
713718733745746754
B 53634418
79936126
802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558
394@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
000-00000Family Practice AssociatesOne Malcolm Ave Teterboro, NJ 07608201-555-1234
( ) A12345 Last Name, First Name
000-0000 123456789
General Health Requisition Form Practice Information
4
Here is an example of practice information you will need to complete your requisition form. S
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ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573@ 571
593599615
713718733745746754
B 53634418 799
36126802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558
394@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
1
2
3
4
000-00000
Family Practice Associates One Malcolm Ave Teterboro, NJ 07608
201-555-1234
( ) A12345 Last Name, First Name
000-0000 123456789
Bar Code Section (Label)
Contains the pre-assigned requisition numbers.
Account #
Identifies the DLO unique client number.
Your Address Section
Client name, address, and phone number appear here.
date Collected
Indicate date specimen is collected.
time
Indicate the collection time, check AM or PM.
1
2
3
4
5
5
DID YOU REMEMBER...TO INCLUDE DIAGNOSTIC CODE(S)?TO REQUEST OR MARK TEST(S)?TO PROVIDE ORDER CODE(S) FOR HANDWRITTEEN TEST(S)TO CHECK “BILL TO” BOX ABOVE?
General Health Requisition Form Test Ordering
5
Pay particular attention to ICD-9 codes and codes for additional tests. It is important to list all medically relevant codes when ordering tests to facilitate payor approval.
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S
ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573
@ 571593599615
713718733745746754
B 53634418
79936126
802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558
394@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
1
2
3
ICd-9 diagnosis Code(s)
Indicate all applicable codes in the boxes provided. Do not include descriptive diagnosis. ICD-9 codes are for billing purposes only and will not be considered as clinical history in the evaluation of Pap Smears.
Additional tests
Indicate all DLO Order Codes for additional tests required that are not preprinted on the Test Requi-sition.
Physician Signature
Physician signature required for Medicaid billing in specific states.
Specimen Key
Available on page 2 of this form.
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2
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ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573
@ 571593599615
713718733745746754
B 53634418
79936126
802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558
394@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
General Health Requisition FormPatient and Billing Information
The information highlighted below must be completed whether your practice, client, Medicare, or Medicaid will be billed for laboratory services. Additional instructions by payor are listed on the following pages.
6
000-0000Family Practice AssociatesOne Malcolm Ave Teterboro, NJ 07608201-555-1234
( ) A12345 Last Name, First Name
1 2
3
1
2
3
4
4
000-0000 123456789
Date of Birth
Sex
Patient Phone Number with Area Code
Provide all applicable ICD-9 Codes for this date of service
DID YOU REMEMBER...TO INCLUDE DIAGNOSTIC CODE(S)?TO REQUEST OR MARK TEST(S)?TO PROVIDE ORDER CODE(S) FOR HANDWRITTEEN TEST(S)TO CHECK “BILL TO” BOX ABOVE?
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ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573@ 571
593599615
713718733745746754
B 53634418 799
36126802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558394
@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
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ON
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ON
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OLLE
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TION
S
ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573@ 571
593599615
713718733745746754
B 53634418 799
36126802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558394
@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
Your General Health Requisition Form allows you to bill different accounts, including your practice’s account, your patient’s account, Medicare and Railroad Medicare, and Medicaid.
to Bill Your AccountWhen billing your account, follow the steps outlined below.
Do Not List Any Insurance Information
General Health Requisition Form Client and Patient Billing
7
12
4
5
6
to Bill PatientWhen billing patients, follow the steps outlined below.
3
Check Patient in the Bill To box
Patient Name
Patient Social Security Number
Responsible Party (RP) Name if other than the patient
Patient/Responsible Party (RP) Address and Zip Code
RP Social Security Number if different from patient
1
2
3
5
4
6
21
Check My Account in the Bill To box
Patient Name
1
2
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NK
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ON
BA
CK
SP
EC
IME
NK
EY
ON
BA
CK
CO
NS
ULT
THE
SP
EC
IME
NC
OLLE
CTIO
NG
UID
EFO
RS
PE
CIA
LIN
STR
UC
TION
S
ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573@ 571
593599615
713718733745746754
B 53634418 799
36126802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558394
@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
SP
EC
IME
NK
EY
ON
BA
CK
SP
EC
IME
NK
EY
ON
BA
CK
SP
EC
IME
NK
EY
ON
BA
CK
SP
EC
IME
NK
EY
ON
BA
CK
CO
NS
ULT
THE
SP
EC
IME
NC
OLLE
CTIO
NG
UID
EFO
RS
PE
CIA
LIN
STR
UC
TION
S
ACCOUNT #:
NAME:
ADDRESS:CITY, STATE, ZIP
TELEPHONE #:
DATE COLLECTED TIME TOTAL VOL/HRS.AMPM ML HR
FastingNon Fasting:
BILL TOMY ACCOUNTPATIENTMEDICARERAILROAD MEDICAREMEDICAIDLabCard/SelectOTHER INSURANCE
BILL TO PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
REGISTRATION # (IF APPLICABLE) SEXM M D D YEAR
PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID #
ROOM# LAB REFERENCE # PATIENT PHONE #
— —
— —
( )PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY#
PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID# GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient)
CITY STATE ZIP
SUFFIX
STATE
RELATIONSHIP TO INSURED: � SELF � SPOUSE � DEPENDENT
MEDICARENUMBER
DATEOFBIRTH
MEDICAIDNUMBER
ICD9 Codes (enter all that apply)STAT
DLO, Diagnostic Laboratory of Oklahoma, the associated logo and all associated Diagnostic Laboratory of Oklahoma marks are the trademarks of Diagnostic Laboratory of Oklahoma.
QD20354M-XO. Revised 10/09.
PR
IMA
RY
IN
SU
RA
NC
E
TOTAL TESTSORDERED
COMMENTS, CLINICAL INFORMATION:
Reflex tests are performed at an additional charge.ADDITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE)
@= May not be covered for the reported diagnosis.F = Has prescribed frequency rules for coverage.& = A test or service performed with research/experimental kit.B = Has both diagnosis and frequency-related coverage limitations.
Medicare Limited
CoverageTests
Providesigned
ABN whennecessary
SM
OO
TH
SE
AL®
ADDRESS:CITY:
Client # OR NAME:
� Fax Results to: ( )
ZIPSTATE
Send Duplicate Report to:
NON-PHYSICIANPROVIDER:
NAME I.D.#
800.891.2917 • www.dlolab.com
NPI/UPINADDIT’L PHYS.: Dr.
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessaryfor the diagnosis and treatment of the patient.
Occult Blood, Feces - Guaiac B 35301 DX B 35306 MCR Scr
Lithium SMagnesium SMicroalbumin, Random Urine w/CreatMicroalbumin, 24 Hour Urine, w/o Creat
Phenytoin SRPhosphorus SPotassium (K) SProgesterone SProlactin SProtein, Total (TP) SPSA, Total SRheumatoid Factor SRPR (Monitoring) w/Reflex Titer SRPR (DX) w/Reflex Confirm SRubella IgG SSed Rate By Mod West LSodium (Na) STestosterone, Total STriglycerides (Trig) STSH STSH w/Reflex T-4, Free ST-3, Total ST-3 Uptake ST-4 (Thyroxine), Total ST-4 (Thyroxine), Free SUA, Dipstick Only UUA, Dipstick w/Reflex Microscopic UUA, Complete (Dipstick & Microscopic) UUA, Complete, w/Reflex Culture
Culture, Group A Strep*Culture, Group B Strep*Culture, Genital*Culture, Throat*Culture, Urine, Routine*(Inc. Indwelling Cath.)Chlamydia DNA Probe, Endocx Or M/Uret
N. gonorrhoeae (GC) DNA Probe, Endocx Or M/Uret
Chlamydia & N. gonorrhoeae w/Reflex ID,DNA Probe, Endocx Or M/Uret
OTHER TESTS
HEMATOLOGY
OTHER TESTS (continued)
7788223234823243249795822285287
4420@ 29256
ABO Group & Rh Type LAlbumin (Alb) SAlkaline Phosphatase (AP) SALT (SGPT) SAmylase SANA w/Reflex Titer SAntibody Scr, RBC w/Reflex ID LAST (SGOT) SBilirubin, Direct (DBili) SBilirubin, Total (TBili) SC-Reactive Protein SCA 125 S
@ 510@ 509
@ 1759@ 6399B 8847@ 763
Hemoglobin LHematocrit LCBC (Hgb, Hct, RBC, WBC, Plt) LCBC w/Diff (Hgb, Hct, RBC, WBC, Plt, Diff) LPT with INR BPTT, Activated B
34392@ 10256
1016510231
B 7600B 14852
20210B 10306
303310
F 10124B 978
330B 334
375@ 418
B 8293 @ 457@ 466
470B 4828477
B 484B 4838435
B 8396B 608B 496@ 512
@ 4848499
@ 498@ 8472
@ 19728@ 7573@ 571
593599615
713718733745746754
B 53634418 799
36126802809836 873
B 896B 899
B 36127859
B 861B 867B 866
@ 6448@ 7909@ 5463@ 3020
173031730417305
448556174558394
@ 395
850285016919
Calcium (Ca) SCarbon Dioxide (CO2) SCardio CRP SCEA SChloride (Cl) SCholesterol, Total (TChol) SCreatinine (Cr) w/eGFR SDigoxin SRDirect LDL SFerritin SFolic Acid SFSH SGGT SGlucose, Gest. Scr. GYGlucose, Plasma GYGlucose, Serum (Glu) ShCG, Serum, Qual ShCG, Serum, Quant SHDL SHemoglobin A1c LHep A Ab, IgM SHep B Core Ab, IgM SHep B Surface Ab Qual SHep B Surface Ag w/Reflex Confirm SHep C Virus Ab SHIV-1/HIV-2 Scr w/Reflexes SIron (Tot), IBC % Sat SIron, Total SLDH SLead (B) TNLH S
Electrolyte Panel SHepatic Function Panel SBasic Metabolic Panel w/eGFR SComp Metabolic Panel w/eGFR S Lipid Panel (Fasting Specimen) SLipid Panel w/Reflex DLDL SObstetric Panel w/Reflex 2L,SHepatitis Panel, Acute w/Reflex S
Source (Required)
ORGAN / DISEASE PANELS
Amplified Specimen Type (please check one)� Endocervical � Urethral � Urine
Stool Pathogens
Chlamydia DNA, SDA
N. gonorrhoeae (GC) DNA, SDA
Chlamydia & N. gonorrhoeae DNA, SDA
100454475
1001930264
681* Additional charge for ID and Susceptibilities
MICROBIOLOGY
Culture, Stool, Culture, Campylobacter*Culture, Salmonella/Shigella*E. coli Shiga Toxins, EIAO & P w/Permanent Stain
(CampylobacterSalmonella/Shigella)*
613@ 622
65174555
294905916
@ 7065@ 92717306
Urea Nitrogen (BUN) SUric Acid SValproic Acid SRVitamin B12/Folic Acid SVitamin B12 SVitamin D, 25 Hydroxy, LC/MS/MS SR
Panel Components on Back
Occult Blood, Feces - FIT, InSure®1
B 11290 DX B 11293 MCR Scr
Affixed Label
to Bill Medicare and railroad MedicareBe sure to complete the Advance Beneficiary Notice (ABN) when appropriate. Refer to page 24 for more detail.
When billing Medicare, follow the steps outlined below.
12
3
1
2
3
4
5
Check Medicare or Railroad Medicare in the Bill To box
Patient Name as it appears exactly on the ID Card
Patient Social Security Number
Patient Mailing Address and Zip Code
Patient Medicare or Railroad Medicare ID Number including the Alpha Prefix or Suffix
8
General Health Requisition Form Medicare and Medicaid Billing
to Bill MedicaidWhen billing Medicaid, follow the steps outlined below.
1
2
4
3
Check Medicaid in the Bill To box
Patient Name as it appears exactly on the ID Card
Patient Social Security Number
Patient Mailing Address and Zip Code
Patient Medicaid ID Number
Include Carrier Name, when appropriate
1
2
3
4
5
6
DID YOU REMEMBER...TO INCLUDE DIAGNOSTIC CODE(S)?TO REQUEST OR MARK TEST(S)?TO PROVIDE ORDER CODE(S) FOR HANDWRITTEEN TEST(S)TO CHECK “BILL TO” BOX ABOVE?
DID YOU REMEMBER...TO INCLUDE DIAGNOSTIC CODE(S)?TO REQUEST OR MARK TEST(S)?TO PROVIDE ORDER CODE(S) FOR HANDWRITTEEN TEST(S)TO CHECK “BILL TO” BOX ABOVE?
4
5
5
6
Side 2
Be sure to use correct specimen abbreviations. All tests ordered on one requisition form should require the same transport temperature.
General Health Requisition Form Reference Information
1 For your assistance, this section lists a specimen key to assist you in the proper collection of specimens.
This table lists the various tests conducted in each organ and disease testing panel. This is located on the specimen key on the front of the requisition.
This area shows the individual testing components that are included in three of the more commonly requested food and allergy profiles.
9
1
2
3
2
3
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