A requisition form is included with every test kit. See below for tips on completing the form to ensure that your test is processed efficiently. In addition, all Medicare-eligible patients must read and sign the ABN on the back of the requisition, regardless of billing method selected. Tests can be significantly delayed or canceled due to missing or incomplete information.
If you have any questions, please contact us.
Please click on the thumbnail images below to view their placement on the form.
Place a check in one of the boxes to choose the method of payment for this test. For more details on the options available, visit our Billing Options and Overview page.
The physician should read and sign the requisition form and verify that the preprinted address and contact information is correct. Please make any needed changes on the form.
Check the box to order the complete profile, when appropriate, or circle individual test components to order separately. Write in any other requested information such as the date of the last sample, patient height and weight, etc. For insurance or Medicare patients, clearly circle and provide diagnosis codes for each component ordered.
Have the patient completely fill out and sign section four. If the patient or responsible party has not signed the form, the test will be placed on hold until a signature can be obtained. All Medicare-eligible patients must read and sign the ABN on the back of the requisition form.
If payment for testing is enclosed, the physician or patient must provide check or credit card information. If complete payment information is not provided, the test will be placed on hold.
If the patient has opted to have Doctor's Data to file a claim with their insurance or Medicare, this section must be completed in full. Any missing information will result in the test being placed on hold.
Write the patient's name and Medicare ID number (Health Insurance Claim Number) at the top.
Explain to the patient that Medicare will probably not pay for the lab tests being ordered for the reasons indicated, and that if the patient decides to proceed with the laboratory tests, they will be responsible for payment. The estimated cost is indicated for each test.
If the patient chooses to receive the tests and accept financial responsibility, but wants Doctor's Data to bill Medicare, choose option 1.
If the patient does not want Medicare to be billed, so they can take advantage of any available prepayment discounts or for other reasons, choose option 2.
If the patient does not want to receive the tests and accept financial responsibility for them, they can check option 3. You will also want them to sign and date the form for your records. In this case, do not send specimens to the laboratory.
All ABNs must be dated and signed by the patient before a test will be performed.