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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

  • Supply Order Form (X06246, 6/16) - For external clients only. Internal Spectrum Health offices order through Lawson. 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. 

 

 

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

 

BILLING FORMS

 

 

CONSENT FORMS

 

 

Requisitions

 

Requisition Name Form # Date Updated

General Laboratory Requisition (with lab locations)

General Laboratory Requisition (no lab locations 1 page)

 LAB443 12/16

Advanced Technology Laboratory (ATL)

Cytogenetics, Flow Cytometry, Molecular Diagnostics

 LAB480

2/17
Allergen Specific IgE Testing LAB495 3/17

Anatomic Pathology (AP)

Cytology (PAP), Histology, Tissue Pathology

 LAB477 12/16
Cystic Fibrosis (CF) Test LAB450

12/10

12/16 Update Pending
Infectious Disease (Microbiology) LAB490 11/16
Pediatric Blood Lead Testing    
Peritoneal Dialysis Labs    
Phone Order   8/14

Quad Form 

Ordered from Mayo Medical Labs

 T595 4/16
Stain Worksheet for AP Testing X16400 11/15
Surgical Specimen Testing by ATL   1/16/18
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