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. Specimen Information
- Include Date and Time Collected and initials of the person who collected the specimen.
- COPY TO: Indicate full physician name (e.g.: Dr. Joe Smith) if an additional copy needs to be sent to another physician.
- Physician signature is REQUIRED in this section for Medicaid patients only.
2. Patient Information
- Fill in patient’s Name and Date of Birth (DOB)
- All other information should be filled in completely or attach a billing face sheet to the requisition.
3. Insurance Billing Information
- Fill in completely or attach a billing face sheet to the requisition.
4. ICD-10/Dx Code
- Fill in the boxes with the appropriate (e.g. medically necessary) diagnosis codes for the tests that have been ordered.
- Please refer to this page on our website for NCD/LCD listings of acceptable medical necessity diagnosis codes.
5. Patient Authorization
- Make sure that the patient signs the authorization.
6. Test Orders
- Please indicate with a check to the left of the test name what test(s) the physician has ordered.
7. Advance Beneficiary Notice (ABN)
The ABN is a separate form that can be obtained from Laboratory Alliance by submitting a Supply Order Request. The ABN only needs to be signed by the patient if the physician feels that the diagnosis code may not be appropriate (not medically necessary) for the test ordered. Please refer to the NCD and LCD websites for coverage determinations:
For LCD information: www.umid.nycpic.com/lcd.html
For NCD information: http://www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf
- Please fill in the patient’s name and Identification Number (Medicare #).
- In the section “Lab Test(s),” please indicate with a check mark the test(s) that you feel that Medicare may not pay for due to the condition of the patient, if it is a frequency limited test, or if the test is for experimental or research only. If a test is not listed and you feel it might fall into one of the above categories, please write the name of the test under one of the blank lines on the form.
- In the section "Reason May Not Pay", check appropriate reason.
- Under “Estimated Cost“, you must provide the patient with an estimated cost of the test(s).
- Under “Additional Information”, any additional clarification for the beneficiary may be entered.
- Under "Options", please have the patient select an option.
- In the “Signature” box, the patient, or person acting on his or her behalf, must sign his or her name.
- In the “Date” box, the patient, or person acting on his or her behalf, enters the date on which he or she signed the ABN.
Important Note: All of the sections of the ABN need to be filled in; otherwise the ABN will not be acceptable by Medicare.