Test requisitions (PDFs) may also be viewed, printed, and downloaded from our website. If necessary, download Adobe Acrobat Reader. To request printed test requisitions, please contact an Integrated Oncology representative:
Brentwood/Phoenix Clients call 866-875-2271
New York Clients call 800-447-5816
Please note: With the launch of IntelliGEN® Myeloid, the reflex options for AML, MDS, and MPN have changed. These updates will be seen on the Hematopathology and Hematology/Oncology test requisition forms.
|Hematology/Oncology (PDF) - Brentwood/Phoenix Clients Only||213.74 KB|
|Hematology/Oncology (PDF) - NY Clients Only||302.87 KB|
|Hematopathology (PDF) - Brentwood/Phoenix Clients Only||227.79 KB|
|Hematopathology (PDF) - New York Clients Only||227.22 KB|
|Gene Profiling Assays (PDF)||200.43 KB|
|Hereditary Cancer Testing||239.38 KB|
|Immunohistochemistry (PDF)||61.19 KB|
|Prognostic/Therapeutic Pathology||287.53 KB|
|Solid Tumor Pathology (PDF)||199.13 KB|
|Children's Oncology Group (PDF)||201.43 KB|
Test Requisition Instructions
Complete the test requisition with all requested information. Ensure all required fields are filled out and information submitted is accurate.
- Client: account #, name, department, address, ordering physician, phone #, physician/authorized signature
- Patient: name, gender, DOB, address
- Billing: insurance company name, policy #, group # (attach face sheet and copy of insurance card)
- Specimen: hospital status when sample collected, specimen ID #s, body site, collection date and time
- Clinical: ICD-CM, clinical indication (attach clinical history and pathology reports), clinical status
- Tests/Services: select tests to be performed
Send a signed, printed copy of the test requisition with your specimens. Please ensure that all information on the test requisition matches the information on the specimens sent (i.e. blocks, slides, tubes).