Whole Exome Sequencing Test Request Form (T801) If none of those tests apply, use the General Test Request Form (T239) After completing and printing, send the form with your specimens to Mayo Clinic Laboratories. Fire Safety 28 CLUSTER THREE: HEALTH INFORMATION MANAGEMENT 29 41. Laboratory Services: Lab Forms and Requisitions. This entails having a place on the form to order panel tests individually — including AMA-defined panels and custom panels. (commonly referred to as Lab Forms). Fill in the boxes with the appropriate (e.g. Spectrum Health Laboratory will no longer accept patient identifier … All other information should be filled in completely or attach a billing face sheet to the requisition. Fill in patient’s Name and Date of Birth (DOB). A piggyback barcode label is constructed of two labels, one label sits on top of the other label but slightly smaller (this is where the word piggybacks comes from). Please fill in the patient’s name and Identification Number (Medicare #). Hours Fasting _____ Certification Program (As of 2013 and stated in The Code of Federal Regulations, CFR42 Part 430, Appendix C, Subpart J, §493.1105 Standard: Record Retention requirements) Listed are the CLIA requirements for retaining patient and testing records, specimens and slides. Accession List 25 34. Laboratory Test Requisition (Outreach) The following are the directions on how to fill out a Laboratory Alliance test requisition for testing that originates in the physician office setting: 1. Microbiology Section: Tel 212.447-6783 Fax 212.447-8258 . laboratory. Lab forms normally include barcode labels along with readable numbers. OTHER TESTING REQUESTS - Please check specimen collection and storage requirements prior to collection Lipase * Indicates tests that may need advanced beneficiary notice (ABN) refer to local and national necessity guide. A scanner on a computer shines LED or laser light on to barcode. You should consult with a professional printing company that specializes in barcode label test requisition forms. Are there different types of test requisition forms (lab forms). Canadian Blood Services Requisitions and Forms ordered by Province. Reporting Test Results 25 35. So, for example if a patient John Smith had blood draw for drug testing for a job and so did Maria Smith the lab will have a way of tracking each specimen so that Johns’ results get to his future employer. For more information on test requisition forms, lab forms, integrated bar code or piggyback barcode label forms please contact Unisource Printing Services and Promotions. The face is then die cut to allow for the removal of a label. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory Patient’s Last Name (as per OHIP Card) If multiple specimens are submitted on one patient which require separate transportation conditions, please use separate biohazard bags and forms. Are there different types of barcode labels on test requisitions forms? RQHR Lab Specimen Requirements - September 2020 How many barcode labels can be placed on a test requisition form? These labels have five layers: a face material, an adhesive layer, a release liner, another adhesive layer, and a backing sheet. The laboratory test request must provide the following information: Ordering provider's full name, address, phone number, and provider signature Without this barcode, there wouldn’t be a way to keep the samples and test forms together. The barcode labels are used to identify corresponding containers with sample to be tested. Unfortunately ISO implementation is frequently accompanied by misunderstandings. HealthLab offers a full range of clinical laboratory tests, specimen collection, consultative and courier services at several immediate care facilities and extended care facilities in the Chicagoland area. Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. This is so lab will know who the samples belong to and where to send the results. Virology Section: Tel 212.447-2864 Fax 212.447-2877 . Under “Additional Information”, any additional clarification for the beneficiary may be entered. The number of barcode labels included on a test requisition form depends on what is determined by what tests will be run per form. Department Memorandum No. Most often the patient’s name and date of birth are included. 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