Requisitions - Mayo Medical Laboratories
Requisitions - Mayo Medical Laboratories
Requisitions - Mayo Medical Laboratories
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<strong>Requisitions</strong><br />
Laboratory Test Requisition (Front)<br />
Laboratory 847-5200 / Pathology 847-5209<br />
1309 Sheldon Road, Grand Haven, MI 49417<br />
Hours and locations on back<br />
LABORATORY TEST REQUISITION<br />
Last Name First MI<br />
Date:<br />
Ordering Provider:<br />
Provider<br />
Birthdate: ___________________ Sex: M F<br />
Signature:<br />
Copies to:<br />
Soc. Sec. # _________________<br />
Nursing Home Resident<br />
Bill Nursing Home (Medicare Part A)<br />
Bill Patient’s Insurance<br />
Name of Nursing Home<br />
Insurance Company Name<br />
Policy Number<br />
DIAGNOSIS (ICD-9 codes required)<br />
TESTS<br />
PANELS<br />
HEPP<br />
BASIC<br />
COMP<br />
LIVP<br />
LIPP<br />
OBP<br />
RENAL<br />
T-CAS<br />
789.00 Abdominal pain<br />
706.1 Acne<br />
626.0 Amenorrhea<br />
285.9 Anemia<br />
280.9 Anemia, iron def.<br />
V28.6 Antenatal Group B Strep SCR<br />
427.31 Atrial fibrillation<br />
600.00 BPH<br />
174.9 CA breast (female)<br />
153.9 CA colon<br />
162.9 CA lung<br />
185 CA prostate<br />
414.00 CAD-nos<br />
786.50 Chest pain<br />
428.0 CHF<br />
496 COPD<br />
V58.61 Coumadin therapy<br />
434.91 CVA<br />
250.01 Diabetes type I<br />
250.00 Diabetes type II<br />
787.91 Diarrhea<br />
626.8 DUB<br />
453.40 DVT (extremity)<br />
788.1 Dysuria<br />
782.3 Edema<br />
796.2 Elevated BP (w/o hypertension)<br />
790.29 Elevated blood sugar<br />
585.6 ESRD<br />
780.79 Fatigue<br />
774.6 Fetal/neonatal jaundice<br />
Hospice Patient Yes No<br />
Bill Hospice Yes No<br />
Hospice Diagnosis:<br />
Acute Hepatitis Profile: (HepBs Ag, HepBc IgM, HepA IgM, HepC Ab)<br />
Basic metabolic panel*: (Na, K, CI, CO2, glucose, BUN, creatinine, calcium)<br />
Comprehensive metabolic panel*: (basic metabolic, total protein, albumin,<br />
bilirubin, AST, alk phos, ALT)<br />
Liver (Hepatic) panel: (albumin, bilirubin, direct bilirubin, alk phos, AST,<br />
ALT, total protein)<br />
Lipid panel+:*(total cholesterol, HDL, triglyceride, calc. LDL)<br />
Obstetric panel: (CBCD, HepBs Ag, rubella, RPR, type antibody screen)<br />
Renal (Kidney) panel*: (Na, K, Cl, Co2, glucose, BUN, creatinine,albumin,<br />
calcium, phosphorus)<br />
Thyroid Cascade+: (TSH will determine further testing options)<br />
530.81 GERD<br />
784.0 Headache<br />
599.70 Hematuria<br />
571.40 Hepatitis, chronic<br />
272.0 Hypercholesterolemia<br />
272.4 Hyperlipidemia<br />
401.9 Hypertension-nos<br />
276.8 Hypopotassemia<br />
244.9 Hypothyroidism<br />
202.80 Lymphoma<br />
627.2 Menopause<br />
626.2 Menorrhagia<br />
729.1 Myalgia<br />
V76.41 Occult Blood Screening<br />
715.90 Osteoarthrosis<br />
COLLECTION INFORMATION<br />
Collected by: _____________ Fasting? Yes<br />
Date:_______ Time: ______<br />
No<br />
Time of Last Dose: _______ Hours:______<br />
(For Therapeutic Drug Monitoring)<br />
Water Only<br />
462 Pharyngitis<br />
725 PMR<br />
V22.1 Pregnancy<br />
V76.44 Prostate – screening<br />
790.93 PSA, elevated<br />
415.19 Pulmonary embolism<br />
593.9 Renal insufficiency<br />
714.0 Rheumatoid arthritis<br />
295.90 Schizophrenia<br />
Additional Diagnoses:<br />
MICROBIOLOGY<br />
Culture – Source:<br />
______________________<br />
If urine: Cath<br />
Clean catch<br />
Aerobic<br />
Anaerobic/Aerobic<br />
Gram stain<br />
Influenza A and B, rapid<br />
RSV<br />
Strep A, rapid<br />
Strep group B culture<br />
Penicillin allergy Yes No<br />
Sputum<br />
Routine culture<br />
AFBx1<br />
AFBx3<br />
Fungusx1<br />
Fungusx3<br />
MRSA screen (nasal)<br />
780.39 Seizures<br />
462 Sore throat<br />
V43.3 Status post valve replacement<br />
V58.83 Therapeutic drug level<br />
435.9 TIA<br />
599.0 UTI<br />
623.5 Vaginal discharge<br />
616.10 Vaginitis<br />
453.40 Venous thrombosis, deep vein<br />
C. difficile toxin A/B<br />
Cryptosporidium Ag<br />
Giardia Ag<br />
Ova & parasite X<br />
(including Giardia/Crypto Ag’s)<br />
Diarrhea (stool) Cascade<br />
Acute (culture, shiga toxin) possible<br />
Giardia, Crypto, leukocyte, C. difficile<br />
Antibiotic (culture, shiga toxin,<br />
C. difficile) possible Giardia, Crypto,<br />
leukocyte<br />
Chronic (culture, shiga toxin)<br />
possible Giardia (X3), Crypto,<br />
leukocyte, C. difficile<br />
Pediatric (culture, shiga toxin,<br />
rotavirus, occult blood) possible<br />
Giardia,Crypto, leukocyte, C. difficile<br />
ALT<br />
AMY<br />
ANA<br />
AST<br />
TBILI<br />
BNP<br />
BUN<br />
CA 125<br />
CA<br />
CBC<br />
CBCD<br />
CEA<br />
CHLM<br />
CORTISOL<br />
CREAT<br />
CRP<br />
CRPHS<br />
CMV<br />
DIG<br />
EBVAB<br />
EMA<br />
ESTRA<br />
FOBSC<br />
FOBDG<br />
FER<br />
FOL<br />
FSH<br />
ALT<br />
Amylase<br />
ANA<br />
AST<br />
Bilirubin total<br />
BNP (Pro-BNP)<br />
BUN<br />
CA 125+<br />
Calcium<br />
CBC (no differential)+<br />
CBC w/differential+<br />
CEA<br />
Chlamydia only<br />
Cortisol<br />
Creatinine<br />
CRP<br />
CRP – high sensitivity<br />
Cytomegalovirus (IgG, Igm)<br />
Digoxin+<br />
EBV antibodies (IgG, IgM)<br />
Endomysial Ab<br />
Estradiol<br />
Fecal Occult Blood Screen (V76.41)<br />
Fecal Occult Blood Diagnostic<br />
Ferritin+<br />
Folate (protect from light)<br />
FSH<br />
GC<br />
GC-CHLM<br />
GLIA<br />
GLU<br />
A1C<br />
HBSAB<br />
HBSAG<br />
HCVAB<br />
HERPES<br />
HCG<br />
HIV 1 & 2<br />
IGA<br />
IRON<br />
IBC<br />
LDH<br />
LH<br />
LIPA<br />
MAG<br />
MAR<br />
MONO<br />
MONOEBV<br />
PHOS<br />
PREGS<br />
PTINR<br />
PSADG<br />
GC- only<br />
GC/Chlamydia<br />
Gliadin Ab<br />
Glucose+<br />
Fasting Random<br />
1 Hr Post Glucola+<br />
Hemoglobin A1c+<br />
HepBsAb (anti-HBs)<br />
HepBsAg (antigen)<br />
HepC Ab (anti-HCV)<br />
Herpes simplex Virus – PCR<br />
HCG, quantitative+<br />
HIV 1 & 2+ consent signed<br />
Immunoglobulin A<br />
Iron+<br />
Iron binding capacity (TIBC)+<br />
LDH<br />
LH<br />
Lipase<br />
Magnesium+<br />
Microalbumin, random<br />
Mononucleosis<br />
Mono/ebv if indicated<br />
Phosphorus<br />
Pregnancy-serum<br />
Protime (PT) / INR+<br />
PSA, diagnostic+<br />
+MEDICARE COVERAGE DOES NOT COVER ROUTINE SCREENING TESTS<br />
+TESTS ARE SUBJECT TO MEDICAL NECESSITY RULES<br />
PSASC<br />
APTT<br />
RETIC<br />
RHOGAM<br />
ESR<br />
T4FREE<br />
T4<br />
FTEST<br />
TESTOST<br />
TTG<br />
TSH<br />
Additional Tests:<br />
PSA, screening (V76.44)+<br />
PTT, activated+<br />
Reticulocyte count<br />
RH Imm glob at NOCH<br />
(includes antibody screen)<br />
Sedimentation rate<br />
T4 free+<br />
T4 total+<br />
Testosterone, free and total<br />
Testosterone, total<br />
Tissue transglutaminase<br />
TSH+<br />
*RECOMMENDED FASTING<br />
TYPE<br />
TS<br />
UA<br />
UACS<br />
UAMIC<br />
UAMCS<br />
B12<br />
VITD25<br />
Type (ABO & Rh)<br />
Type and screen<br />
Urinalysis (microscopic if ind)<br />
Urinalysis (microscopic and<br />
C&S if indicated)<br />
Cath Clean catch<br />
Urinalysis w/microscopic<br />
Urinalysis w/microscopic<br />
(C&S if indicated)<br />
Cath Clean catch<br />
Vitamin B12<br />
Vitamin D<br />
LAB-146 (r6-11)
Laboratory Requisition (Back)<br />
W<br />
N<br />
S<br />
E<br />
Pontaluna<br />
Airline<br />
31<br />
N 3rd St.<br />
4<br />
Savidge<br />
Fruitport<br />
2<br />
96<br />
Sheldon Rd.<br />
1<br />
Taylor Ave.<br />
1 MAIN LAB<br />
2<br />
North Ottawa<br />
Community Hospital<br />
1309 Sheldon Road<br />
Grand Haven<br />
LAB MILL POINT<br />
Mill Point Health Center<br />
601 Savidge<br />
Spring Lake<br />
Hours:<br />
Monday - Friday<br />
6:30 AM - 5:30 PM<br />
Saturday<br />
6:30 AM - 12:00 PM<br />
Phone: (616) 847-5382<br />
Hours:<br />
Monday — Friday<br />
7:00 AM to 3:30 PM<br />
Phone: (616) 604-2500<br />
S. Beacon Blvd<br />
31<br />
3 4<br />
LAB STANTON CROSSINGS<br />
15151 Stanton, Ste B<br />
West Olive<br />
Hours:<br />
Monday - Friday<br />
7:00 AM to 12:00 PM<br />
Phone: (616) 502-5028<br />
LAB EAST<br />
Third Avenue Family Clinic<br />
14 N. 3rd Avenue<br />
Fruitport<br />
Hours:<br />
Tuesday & Thursday<br />
7:00 AM to 12:00 PM<br />
Phone: (616) 865-3602<br />
Lake Taylor Michigan Ave. Drive<br />
Fillmore Taylor Ave.<br />
3<br />
Stanton Taylor Ave. St.<br />
152 nd Ave.<br />
Taylor Ave. St.<br />
Please feel free to use any of our 4 convenient Laboratory Locations.<br />
Where you need us most!
Pathology/Tissue/Cytology Requisition
Advance Beneficiary Notice (ABN)
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