Get Referred Patient Requisition Form - Laboratory Services - Arkansas ... - Archildrens

Completing the Referred Patient Requisition Form for laboratory services at Arkansas Children's Hospital is an essential step in ensuring that patients receive the necessary medical tests. This guide provides detailed instructions to help users accurately fill out the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access and open the form in a suitable document editing tool.
2. Enter the date in the designated field at the top of the form.
3. Fill in the referring institution’s name and contact information, including the contact person's name and phone number.
4. Provide the patient's name, 8-digit ACH account number, 6-digit ACH unit number, sex, and date of birth.
5. List all diagnosis codes for each lab ordered in the appropriate section under 'Diagnosis / ICD9 Code(s).' Ensure each diagnosis is clearly stated.
6. Include the fax number for sending the completed requisition.
7. Attach a copy of the patient's ID and insurance card as required by the form.
8. Input the referring or ordering physician's name and ensure to sign the form, certifying the medical necessity of the tests.
9. Indicate the specimen type by circling the correct option from the list provided.
10. Fill in the collection date and time for the specimen.
11. Clearly mark the applicable tests by selecting them from the options listed on the form.
12. After completing all fields, review the information for accuracy, save any changes, and prepare the document for submission.
13. You can print, download, or share the completed form as needed.

Start completing your Referred Patient Requisition Form online today for efficient lab service.