US BioTek Laboratories - Requisition Form

Interactive Requisition Form (All Tests) PDF - 2.2 MB

How to Complete Test Requisition Form

• Print patient's name legibly, last name first.
  
• Print patient's address, age, sex, date of birth and day and evening phone numbers.
  
• Record specimen collection date, collection time, date specimen is sent, and storage conditions if the specimen is not mailed immediately after collection (i.e. room temperature, frozen, refrigerated).
  
• Clearly mark the requested test panel(s).
  
• Requisition form must be signed by the ordering physician.
  
• Check the appropriate box for billing. No other information is required when physician/ practitioner marks “bill physician”.

Insurance Billing

• Print insurance provider name, address and contact number.
  
  
• Print name of subscriber, date of birth and relation to patient.
  
  
• Provide policy number, member ID and group number.
  
  
• Enclose a copy of insurance card (front and back).
  
  
• Sign the Insurance Agreement.
  
  
• Indicate ICD-9 (International Classification of Disease).

Credit Card Billing

• Provide card number, expiration date, cardholder's name, signature and amount in USD.
  
  
• The above information can be omitted if physician/practitioner has their credit card information on file with US Biotek Laboratories.

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