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This document serves as a requisition form for the Autoimmune Brain Panel™, formerly known as the Cunningham Panel™. It outlines the necessary patient and guardian information, billing options, and instructions for submitting the requisition. The panel is intended to assess autoimmune reactions impacting brain function and includes details on testing costs, insurance reimbursement, and submission procedures for both patients and healthcare providers.

How to fill out test requisition

How to fill out test requisition

1. Collect patient information: gather the patient's name, date of birth, and contact information.
2. Obtain physician details: input the name and contact information of the referring physician.
3. Select the tests required: mark the specific tests that need to be performed from the provided list.
4. Provide clinical information: include any relevant history or symptoms that support the necessity for the tests.
5. Specify any special instructions: mention if there are any specifics regarding fasting or timing for specimen collection.
6. Review and sign: ensure all information is accurate, then sign the requisition form.

Who needs test requisition?

1. Healthcare providers who require laboratory tests for diagnosis or treatment.
2. Patients needing testing as part of their medical evaluation.
3. Laboratory personnel who need clear instructions for processing tests.

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What is test requisition?

A test requisition is a formal request for laboratory testing, typically including patient information, the specific tests required, and clinical details.

Who is required to file test requisition?

Healthcare providers, such as physicians or nurse practitioners, are required to file test requisitions on behalf of their patients.

How to fill out test requisition?

To fill out a test requisition, provide accurate patient information, specify the tests requested, include the reason for testing, and sign as required.

What is the purpose of test requisition?

The purpose of a test requisition is to formally communicate necessary laboratory tests to be conducted on a patient and ensure proper testing protocols.

What information must be reported on test requisition?

Information that must be reported includes patient's name, date of birth, identification number, tests requested, clinician's name, and relevant clinical information.