Test Requisition Forms are supplied by the laboratory

Test Requisitions Forms 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)

If you are in need of an Accutix Test Requisition Form please email
our Sales Operations team at OI_SalesOps@questdiagnostics.com