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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 & Requisitions

FORMS

 
ORDERS: Additional / Add-On Test Request (9/20)
ORDERS: Blood Bank Specimen Form (4/17)
ORDERS: Test Cancellation (4/20)
SPECIMEN: Corrected Report - Gen Lab
SPECIMEN: Corrected Report - Pathology

SUPPLIES: SHMG Supply Order Form (X24639)
SUPPLIES: NON-SHMG Supply Order Form (X06246)
OFFICE: New Lab Client Request 
OFFICE: Office Moving or Discontinuing Services Update (12/16)
BILLING: Account Correction, Adjustment or CREDIT for patient billing (5/19)
BILLING: Update Patient Diagnosis Code
BILLING: ABN (Advanced Beneficiary Notice) (X13553)

CONSENT: HIV Consent Form

- English

- Spanish

- Arabic
CONSENT: 

REQUISITION/PAPER ORDERS**

See important note below table
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 
Stain Worksheet for AP Testing
Surgical Specimen Testing by ATL
Veterinary Clinic Sample
SHMG/SH Epic Downtime Requisition

**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