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Laboratory Services 9811 Woods Drive Suite H180 Skokie IL 60077 www. northshore. org Phone 847 663-2100 Ver 1/2015 Fax 847 663-2101 PATIENT STANDING ORDER REQUEST FORM PATIENT ONE TIME REQUEST FORM Account Name NSLS Account No Physician Name One time order request Standing order request Unless indicated standing orders expire twelve months 12 from order date Patient Name Date of Birth Patient Address Gender Billing Information Client Bill Test Code Patient Bill Test Name Medicare NorthShore IPA ICD-9 Additional copies to Effective Date Expiration Date Frequency Fax Number Physician Signature Although current guidelines from the Office of the Inspector General OIG do not prohibit the use of standing orders they specifically discourage their use. The guidelines do require that the written orders be obtained that an expiration date be included and that the order itself does not constitute medical necessity. Additional documentation an ICD-9 code at a minimum may be required* OIG warns that the use of standing orders may result in unnecessary testing as defined by Federal Statute. The guidelines do require that the written orders be obtained that an expiration date be included and that the order itself does not constitute medical necessity. Additional documentation an ICD-9 code at a minimum may be required* OIG warns that the use of standing orders may result in unnecessary testing as defined by Federal Statute.

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