Get the free Clinical Laboratory Requisition Form - www2 erie

ERIE COUNTY PUBLIC HEALTH LABORATORY 503 Kensington Avenue, Building AA, Buffalo, NY 14214 Tel: (716) 8986100 Fax: (716) 8986110 Email:ECHL Erie.gov Patient Name : PATIENT & PROVIDER INFORMATION Date

How to fill out clinical laboratory requisition form

How to fill out a clinical laboratory requisition form:

1. Start by entering the patient's personal information, including their name, date of birth, and any other identifying details requested on the form.
2. Specify the healthcare provider who is ordering the laboratory tests by providing their name, contact information, and any other required details.
3. Indicate the date when the requisition form is being filled out.
4. Identify the specific tests or panels that are being requested by checking the appropriate boxes or writing the test names clearly. Include any additional instructions or special requirements for the laboratory.
5. If necessary, provide clinical information such as the reason for the tests, any relevant medical history, and specific symptoms or concerns.
6. Verify the insurance information by including the patient's insurance identification number, policyholder's name, and any other required details. If the patient does not have insurance, indicate this as well.
7. Sign and date the requisition form as the healthcare provider, confirming the accuracy and necessity of the requested tests.
8. Make a copy of the completed requisition form for your records and ensure that the original is sent to the laboratory for processing.
9. Follow any additional instructions provided by the laboratory, such as collecting and preparing the samples for testing.
10. Keep the patient informed about the laboratory test results and any further actions or treatments that may be needed based on the results.

Who needs a clinical laboratory requisition form:

1. Healthcare providers such as doctors, nurses, or physician assistants who want to order laboratory tests for their patients.
2. Patients who have been referred for specific tests by their healthcare providers.
3. Laboratories that require a formal request or authorization before conducting any diagnostic or screening tests.

For pdfFiller’s FAQs

What is clinical laboratory requisition form?

The clinical laboratory requisition form is a document used to request specific tests or analyses from a clinical laboratory.

Who is required to file clinical laboratory requisition form?

Healthcare providers, doctors, or medical professionals are required to file the clinical laboratory requisition form.

How to fill out clinical laboratory requisition form?

To fill out the clinical laboratory requisition form, provide patient information, requested tests, date of specimen collection, and any other required information.

What is the purpose of clinical laboratory requisition form?

The purpose of the clinical laboratory requisition form is to ensure that the laboratory performs the correct tests requested by the healthcare provider.

What information must be reported on clinical laboratory requisition form?

The clinical laboratory requisition form must include patient's name, date of birth, gender, requested tests, healthcare provider's information, and date of specimen collection.

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