Follow the steps to accurately complete the requisition form.

1. Press the ‘Get Form’ button to access the requisition form and open it in your preferred editing tool.
2. In the first section labeled ‘Ordering Physician/Laboratory,’ provide the first and last name, NPI, practice name, complete address, phone number, and fax number of the ordering physician. Ensure that all required fields are filled out completely.
3. Under ‘Collector signature,’ ensure that the person collecting the specimen signs the form.
4. In ‘Specimen Collection Information,’ enter the number of specimen vials submitted and the date collected, which are required fields.
5. Indicate the site and type of specimen collected by selecting the appropriate options from the provided checkboxes for each of the specimen categories (B-E). Include additional details if applicable.
6. Provide patient information in the ‘Patient Information’ section, including address, gender (which is required), date of birth (required), and contact details including phone number and email.
7. In the ‘Billing Information’ section, ensure to detail all necessary billing information, including patient billing and insurance billing. A copy of the front and back of the insurance card should be submitted.
8. Complete the ‘Diagnosis Codes’ section by providing all applicable codes. This is also required information.
9. Fill out the ‘Procedure’ section, indicating the type of procedure that will be performed. Include relevant details like the date and time collected.
10. Designate the physician to receive additional result reports if necessary, and ensure that any required signatures are provided.
11. After completing all sections of the form, save your changes. You can download, print, or share the form as needed.

Complete your MDL Surgical Pathology Gynecology Test Requisition online today for streamlined processing.