LABORATORY TEST REQUEST FORM
HealthLink Laboratory provides its customers with test request forms (along with supplies to collect the
specimen to simplify ordering.
request form must accompany each specimen. In order to provide accurate service, we ask that you fill out the
form completely as described below.
Keep the office copy for your files.
Roll your mouse over the
numbered sections of the form and a description will pop up in a
small yellow window.
Enter your institution’s code, requesting physician’s name and UPIN code.
Check the block to indicate how this is to be billed:
Bill account (bill institution or physician office)
Bill the patient
Bill Medicare/Medicaid (provide further information)
Bill insurance (must complete gray shaded area)
Enter patient demographics. It is very important to include all requested information if we are to bill the
patient or their insurance.
Always give date of birth of the patient. This insures that the correct normal values will print with the test
Enter the patient's social
Enter the patient’s Medicare, Medicaid, or commercial insurance in the gray shaded area marked “Billing
Information.” For insurance billing, this must be filled out completely.
You may send a copy of the insurance card, both front and back.
If the patient has insurance billing,
provide an employer name and phone number.
Provide an appropriate diagnosis/ICD9 code to indicate medical necessity.
A written description is
acceptable, although an ICD9 code is preferred.
Always provide a date of collection and, if necessary, a time collected.
To select a test, place an X in the space next to the test name.
To write in a test that is
not printed on the reguest form, or to make comments to aid the
technician in performing the test, use the space provided.
In this section, the patient must sign and date the Advance Notice section indicating that he/she
understands that the
test(s) ordered may not be covered by Medicare and that he/she will accept financial responsibilty for the test. The reason for denial must be indicated by marking A, B,