Test Requisitions

Test Requisitions

To request printed test requisitions, please contact an Integrated Oncology representative:
Brentwood/Phoenix Clients call 866-875-2271
Shelton/New York Clients call 800-447-5816

 

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).