If you are one of our supplier partners, you can print the forms below to order labs for a patient. The patient can travel to any of our locations using the completed form signed by a provider to take a blood test and test. When you attract the patient to your facility, send both the completed form and the copy with our couriers. You can also print a lab application sheet from your EMR if you prefer. We can provide you with pre-printed notebooks of these order forms upon request. All referring physicians must provide complete information, including the NPI# and/or UPIN# when a sample is first submitted. Once this doctor has been added to our database, the doctor`s name, office location and MDL account number are sufficient. Customer Requirements – Please request requests via the delivery order form or contact Nationwide Children`s Laboratory Services at (614) 722-5477 or (800) 934-6575. Test request forms (lab forms) are available in black and white or color. For each patient, a test request form (OBGYN test request form or urology test request form) must be submitted and completed in accordance with the instructions below. Piggyback barcode labels are well suited for printed or continuous handwritten test request forms. However, they do not work at all with digitally printed forms (laser printed).
The heat from the laser printer melts the adhesive and blocks your machine. This is our standard application form, with the most common lab tests available to order. This is our small requirement form, which is a subset of the above standard. The ACL requirement is designed to collect accurate information, as required by federal or private health programs, and to promote the easy and accurate ordering of appropriate, necessary and record-supported tests. The following sample verification request form has been numbered 1 to 5 for reference for each of the following 5 steps. A billing option must be enabled. If no information is provided, the patient will be billed directly. When submitting information from third parties, fill in all the fields or simply attach a photocopy of the front and back of the patient insurance card. Be sure to provide the appropriate diagnostic codes when submitting samples for patients billed by third parties. Depending on the type of tests performed, specific consent may be required.
For more information on consent forms, please contact Laboratory Services at (614) 722-5477 or (800) 934-6575 or Laboratoryservices@Nationwidechildrens.org. The number of barcode labels included in a test request form depends on what is determined, which tests are run per form. If it`s all blood products, you can get from 1 to more than 30 because the barcode label is smaller than tissue and urine sample containers. Can I put more information on the barcode label included on the test request form? Patients who are referred to one of our laboratory service centers must proceed with the registration and submit the written order from the laboratory test provider. In some cases, such as . B genetic testing, consent may be required. A laboratory test prescription is required (e.B. Paper application, electronic medical record, ChildLink™ provider). The laboratory test request must contain the following information: For the DNA Repair Assessment (DDRFL) Patient Information Form, click here. Contact us for detailed information on the different types of test request forms – we will be happy to help you. Below are instructions for completing a Laboratory Alliance test request for tests from the doctor`s office: For more information about test request forms, lab forms, embedded barcode forms, or piggyback barcode label forms, please contact Unisource Printing Services and Promotions. The NBA is a separate form that can be requested by the Laboratory Alliance by submitting a supply order request.
The NBA should only be signed by the patient if the doctor considers that the diagnostic code for the ordered test may not be suitable (medically necessary). Information on coverage requirements can be found on the DTM and LCD websites: additional information can be added to barcode labels on test request forms. Most often, the patient`s name and date of birth are included. This information is a second check for the laboratory performing the tests. Standard label requirements include the following information on the sample label: A test request form must be submitted for each patient. If multiple samples are submitted to a patient that require separate conditions of transport, please use separate Biohazard bags and forms. There are two types of test request forms: piggyback labels; and built-in barcode labels. If you want your application form to be printed on a laser or handwritten printer, the best way is to use built-in barcode labels. If you are using a continuous or handwritten printer, you can use a piggyback barcode label. Please fill in all of the following information in this section. It is important not only for positive patient identification, but also for billing purposes. Please ensure the accuracy and legibility of all patient information.
For more information about running a request, see the sample test request below. Questions or concerns regarding compliance with the requirements can be directed to Children`s Laboratory Services Nationally at (614) 722-5477 or (800) 934-6575. Test request forms usually contain barcode labels as well as legible numbers. Barcode labels are used to identify the appropriate containers with the sample to be tested. Custom label sizes are available on lab forms. There are many standard-sized labels you can choose from to avoid additional matrix fees. You should contact a professional printing company that specializes in barcode label test request forms. A test request form is used by healthcare professionals to request laboratory tests such as urine or blood tests. Test request forms are often referred to as laboratory forms.
If blood, urine or tissue is sent from a doctor`s office to a laboratory, a test request form is required. The demographic data of the patient, the attending physician, the insurance information and the test to be performed can be found on this form. There are different types and variants of test request forms (lab forms): there are laser-printed one- or multi-part NCR forms, multi-part handwritten NCR forms, and computer-printed multi-part NCR forms that are fed with pins. The date of collection is a very important piece of information, often overlooked. If the actual transport time exceeds the recommended time, the integrity of the results may be compromised. It is also important to determine the order of the samples during the series tests. Please indicate the source of a sample other than blood. This is especially important for biopsies and body fluids. This is our laboratory requirement form for animal/animal testing. For more information about NCDs: www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf When ordering lab tests for patients participating in Medicare or other government-funded insurance programs, reimbursement may be limited to: For the Biochemical (Metabolic) Genetics Clinical Data Form, click here.
Don`t forget to include all the tests that are ordered on the test request! Positive patient identification and accurate sample tagging are essential for reliable sample analysis and reporting. The sample label must contain a primary identifier and a secondary identifier. For the tissue scroll sample calculator for genetic testing, click here. Samples may be considered unacceptable for analysis if: Full name, address, telephone number and signature of the provider`s BMT transplant/chimerism application, click here For the hematology flow cytometry request, click here. Notification of unacceptable samples will be provided to the customer by Nationwide Children`s Laboratory Services. Written documentation of the event will be included in the patient`s report. . Built-in barcode labels take on many variations, but a basic definition would be the application of a label lining material to the back of a sheet. The face is then punched to allow the removal of a label. The lining may have an NCR coating so you can write on the label and move on to the second sheet.
A piggyback barcode label consists of two labels, one label is on the other label, but slightly smaller (hence the word piggybacks). These labels have five layers: a surface material, an adhesive layer, a release film, another adhesive layer and a load-bearing film. To consult the pathology consultation request form, click here. Test samples may be referred to children`s laboratory services nationwide or patients may be sent to our laboratory service centres for sampling and delivery. Important note: All sections of the NBA must be completed; Otherwise, the NBA will not be accepted by Medicare. .