Requisitions

Sarasota Memorial Laboratory Services Test Requisition

Completing the Sarasota Memorial Laboratory Services Test RequisitionPrint or type information. It is important that all information is legible. Please follow these steps to ensure timely and accurate processing.

Physician Information

• Complete the REFERRED BY located on the upper right-hand corner by listing:

—Physician name or provider organization name (facility)

—Street address, phone number, and fax number

Specimen Collection Information

• In the collection section located in the top left-hand side of the requisition, enter the COLLECTION DATE, COLLECTION TIME, and COLLECTED BY

• Indicate whether patient needs to be fasting by placing an “X” in appropriate box

• Indicate if STAT priority is required by placing an “X” in appropriate box

• If collecting specimen(s) using a “stickered” requisition, place 1 sticker on each specimen collected (this provides 1 identifier of 2 required identifiers)

Patient Information

• Enter PATIENT NAME with last name first, then first name, and ending with middle initial. The patient name MUST agree with the name on the specimen(s) since it is always used as a patient or specimen identifier.Note: The patient name and another identifier are

required to establish the identity of the patient or specimen. In addition to the patient’s name, other identifiers include:

• Birth date• Social Security number• Requisition number (label provided)

• Enter patient’s SEX, BIRTHDATE, and SOCIAL SECURITY NUMBER

• Patient’s ADDRESS and PATIENT PHONE are necessary if insurance or the patient is to be billed

• The REQUESTING PHYSICIAN is required• Enter DIAGNOSIS (ICD-9) information; this is required

for billing purposes

Billing Information

• Indicate payor by marking:—CLIENT - provider to be billed at client pricing—PATIENT - patient is to be billed directly as self-

pay—INSURANCE - other third party payor such as

Medicare, Medicaid, etc.• Enter the relationship of the insured to the patient above

RELATIONSHIP• For proper billing, the STREET ADDRESS and CITY,

STATE, and ZIP CODE need to be completed• For billing insurance, including Medicare and Medicaid,

the following must be completed:—POLICY #—SOCIAL SECURITY # of responsible party—NAME AS APPEARS ON insurance CARD of

responsible party—INSURANCE COMPANY ADDRESSNote: If billing information is available from the responsible party’s insurance card or a billing face sheet, a legible copy of either may be attached to the Sarasota Memorial Laboratory Services Test Requisition in lieu of filling out the billing information on the requisition.

Testing Required

• Indicate which tests are ordered by placing a check or “X” in the box next to the test needed

• If testing is needed which is not listed, enter the name of the test(s) in the MISCELLANEOUS TESTS section

• If a culture is submitted, provide the culture source if not specified on the line

Place remaining requisition with specimen in a biohazard bag and seal tightly. Please, 1 patient’s specimen with 1 requisition per bag.

Sarasota Memorial Laboratory Services Supply Order Form

Sarasota Memorial Laboratory Services- Supply Order Form

Item Description Quantity Notes Item Description Quantity NotesVACUTAINER® tubes MICROTAINER® (bags of 50)(Packs of 100) Lavender6.0-mL gold gel Plain (red/no gel)10-mL plain red Red gel4.5-mL light green gel Green (lithium heparin)3.0-mL lavender4.5-mL blue VACUTAINER® needles5-mL gray (Box of 48) 21G5-mL dark green (Boxof 48) 22GPPT viral load (each)

Specimen bags (100) Glucose tolerance beverageGallon jugs with caps 50-gm bottleUrine collection kits 75-gm bottleSterile urine cups 100-gm bottleOccult blood cardsO & P kits Laboratory RequisitionsCulturettesBlood culture bottlesBlood culture prep kit ***FACILITY/OFFICEPediatric BC bottles *** ADDRESS:NPG Culterettes

Office phone #

Ordered by Date

***Please fax this order to 917-2274

Please allow 48 hours for delivery of supplies. Thank you for your business !

Any questions please call 917-1350 Option 5