Facilities using Manual Test Requisition Forms to order tests – as opposed to using our web portal to digitally complete test requisitions – must make sure their test requisition forms are fully complete to ensure the smoothest workflow for our Operations Department. Blank Manual Test Requisition Forms can be requested through supply orders.

Note: All content boxes highlighted in pink must be filled in for form to be accepted.

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1. Labeling:

  • Place corresponding label within rectangle.

2. Patient Information:

  • Print clearly the following information:
    • Patient’s Full Name
    • Patient’s Social Security Number
    • Patient’s Birth Date
    • Patient’s Room Number
    • Patient’s Gender (Male/Female)
    • Medicare/Medicaid Number
    • Billing Information
    • Referring Physician

3. Symptoms:

  • Enter ICD-10 Code/Symptoms
    • Correct ICD-10 Codes are necessary to prove medical necessity to ensure proper reimbursement from Medicare

4. Test Order:

  • Check off corresponding box for any tests ordered
    • Additional test instructions must be written in the “Specific Test Instructions” box

5. Doctor/Nurse’s Signature:

  • All forms must have the following to be complete:
    • Authorization to Draw from the Patient
    • Authorization to Report Patient’s Results

6. Advanced Beneficiary Notice:

  • Make sure the following information is collected:
    • Patient’s Name
    • Medicare Number
    • Which additional tests patient is requesting, if any.
    • Have resident decide whether they want to receive the tests and check off appropriate box, if any
    • If no ABN is signed, uncovered tests will become facility’s responsibility.

7. ICD-10 Codes Help Sheet:

  • On the back of the pink carbon copy is a reference for ICD-10 codes supplied by Aculabs.

8. Common Tests Help Sheet:

  • On the back of the yellow carbon copy is a reference for common tests and corresponding tube color supplied by Aculabs.