Forms and Requisitions
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 - Gen Lab (2/17) - Form to correct specimen and requisition label for general lab work.
- 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.
- Test Cancellation (9/16) - To cancel a test in the Epic/EMR system
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
- Account Correction, Adjustment or CREDIT for patient billing (5/19) - Form to credit testing, billing adjustments or to update diagnosis
CONSENT FORMS
- Informed Consent for Genetic Testing - English (X17150, 1/15)
- Informed Consent for Genetic Testing - Spanish (X19216, 7/16)
- Informed Consent for Genetic Testing - Patient Education Book - English (8/15) - Provided by the Michigan Department of Health & Human Services
- Authorization of Release of Information Form (X01743, 4/19, English)
Requisitions
*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
- Downtime Requisition
- Emergence Department (ED) Downtime Requisition
- Downtime Requisition - Histology/Tissue Pathology