Get the free Outpatient Lab Request Form JAN 2014 - UW Health - uwhealth

Check box to mark request(s) DO NOT USE HIGHLIGHTER Clinical Laboratories MAN: 600 Highland Ave., Madison WI 537922472 (608) 2637060 ALL FIELDS ARE REQUIRED Patient name: (Last, first, MI) Order Date

How to fill out outpatient lab request form

How to fill out an outpatient lab request form:

1. Start by filling out your personal information in the designated fields. This typically includes your full name, date of birth, and contact information.
2. Next, provide your healthcare provider's information, such as their name, practice name, and contact details. Make sure to double-check the accuracy of this information.
3. Indicate the type of test(s) you are requesting by selecting the appropriate checkboxes or writing them in the provided space. If you are unsure about the specific tests, consult with your healthcare provider.
4. Include any relevant medical history or symptoms that may assist the lab technician in understanding the purpose of the requested tests. This could involve writing a brief description or attaching any relevant documents or reports.
5. If you have insurance coverage, provide your insurance information, including your policy or group number. Additionally, if your insurance requires prior authorization for the requested tests, you may need to include the relevant information or obtain it separately.
6. Review the form for completeness and accuracy before submitting it. Ensure that all required fields are filled out, and there are no spelling or typographical errors.
7. Finally, sign and date the form to authorize the lab to perform the requested tests. Keep a copy of the form for your records and submit the original to the appropriate healthcare facility.

Who needs an outpatient lab request form?

1. Patients who have been referred for specific diagnostic tests by their healthcare provider may need to fill out an outpatient lab request form. This could be for routine screenings, monitoring of chronic conditions, or investigating specific health concerns.
2. Individuals who are seeking a second opinion or wish to undergo additional testing outside of their regular healthcare provider's scope may also require an outpatient lab request form.
3. Employers or insurance companies may request employees or policyholders to complete an outpatient lab request form as part of pre-employment or insurance-related medical examinations.

Note: The requirements for filling out an outpatient lab request form may vary depending on the healthcare facility and the specific tests being requested. Always consult with your healthcare provider or the lab facility if you have any questions or need clarification on how to complete the form accurately.

For pdfFiller’s FAQs

What is outpatient lab request form?

An outpatient lab request form is a form that is used to request laboratory testing for patients who are not admitted to the hospital.

Who is required to file outpatient lab request form?

Medical personnel such as doctors, nurses, or other healthcare providers are required to file outpatient lab request forms on behalf of their patients.

How to fill out outpatient lab request form?

Outpatient lab request forms can be filled out by providing patient information, test requested, medical history, and other relevant details.

What is the purpose of outpatient lab request form?

The purpose of an outpatient lab request form is to request specific laboratory tests for patients in an outpatient setting.

What information must be reported on outpatient lab request form?

Information such as patient's name, date of birth, contact information, test requested, referring provider, and any relevant medical history must be reported on the outpatient lab request form.

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