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Forms and Requisitions

Important Note

Click on the links below. Note: These are all pdf files and may have to be downloaded to view.

Forms

LAB FORMS

  • Additional / Add-On Test Request (5/16) - Each add-on request will be investigated by lab for appropriateness. If the specimen is still viable, testing will be completed and results sent, if not, a call will be made to the clinician.

 

  • Blood Bank Specimen Form (4/17) - For any Blood Bank Test (except Prenatals) ordered on an outpatient, this form must be filled out.

 

 

  • Corrected Report - Pathology (1/17) - Form to correct specimen designation or procedure. Spectrum Health Laboratory will no longer accept patient identifier corrections to specimens considered non-precious.

 

 

LAB SERVICES FORMS

  • SHMG Supply Order Form (X24639) - Spectrum Health and Spectrum Health Medical Group should order supplies via Workday when available.
  • Supply Order Form (X06246) -  Outpatient Lab Supplies are filled 8 am - 5 pm, Monday - Friday, excluding holidays. Fax filled form to the number on the form. Supplies may take up 5 days to deliver. Contact the Lab Call Center with pick up requests or questions: 616.774.7721. Some items may be ordered through Lawson for Spectrum Health owned entities.

 

 

  • Office Location Update (12/16) - Office is moving notification for Laboratory Client Services and Laboratory Courier Services

 

BILLING FORMS

 

 

CONSENT FORMS

 

 

Requisitions

 

Requisition Name

General Laboratory Requisition 

Advanced Technology Laboratory (ATL)
Allergen Specific IgE Testing

Anatomic Pathology (AP)
COVID19 SARS-COV2
Cystic Fibrosis (CF) Test
Infectious Disease (Microbiology)
Pediatric Blood Lead Testing
Peritoneal Dialysis Labs
Phone Order

Quad Form 
SHMG/SH Epic Downtime Requisition
Stain Worksheet for AP Testing
Surgical Specimen Testing by ATL
Veterinary Clinic Sample

 

 

*IMPORTANT NOTE: The following information is required on all laboratory requisitions, failure to provide this information may result in delay of results or possible specimen cancellation and request for recollection

 

Patient Information

  • Full name (legal name) including middle initial
  • Birth Date
  • Address and Phone Number

Billing Information

  • Policy holder name
  • Policy holder address
  • Insurance name, address, and type
  • Contract, Plan or Group Numbers
  • Policy holder’s employer
  • Relationship to patient
    • Note: A copy of patient’s insurance card (front and back) is advised.

Provider Information

  • Ordering and Attending Provider Name
  • Ordering Provider Organization Name
  • Ordering Provider Address, Phone AND Fax.

Specimen Collection Information

  • Date and Time of Collection
  • Specimen Type
  • Source

 

To have a customized laboratory requisition please contact your Laboratory Account Manager or call the Laboratory Customer Service Support Team at 616.774.7721 or email LaboratoryServices@spectrumhealth.org.

 

FOR SPECTRUM HEALTH INPATIENT USE, IN DOWNTIME EVENT