Test Requisition Forms are supplied by Imugen

Test requisitions must include the following information:

  1. Name of authorized submitter (i.e. hospital, laboratory, physician office name)
  2. Physician name (if different from the submitter)
  3. Submitter address, telephone number, and FAX number
  4. Date of collection
  5. Type of specimen (Serum, CSF, Synovial Fluid, EDTA, Plasma)
  6. Patient name (last, first), address, and telephone number
  7. Date of birth
  8. Submitter accession number (i.e. Hosp Rec. #)
  9. Test requested
  10. Third-party billing information (i.e. Medicare/Private Insurance)
  11. Diagnostic or other information (i.e. ICD-10 codes as required by Medicare or other authorized payers)

The Test Requisition Form contains an optional clinical information section. Providing relevant clinical information will assist laboratory staff in providing more detailed interpretation of test results in each case.

 

Downloadable Requisition Forms:

If you are a Hospital or other Institution, please download the Institution Requisition Form.

If you are a Physician, please download the Physician Requisition Form.

If you are a Hospital or other Institution within New York State, please download the NY ONLY Institution Requisition Form.

If you are a Physician within New York State, please download the NY ONLY Physician Requisition Form.

If you need assistance, please contact a member of our staff after downloading the requisition forms.