Please attach a copy of the registration FACESHEET and INSURANCE Card(s) to this form
Collect Date: Collect Time:
MEDICAL RECORD #
Location
PRINT Ordering Physician/Practitioner NAME: REQUIRED
NAME:
Ordering Physician/Practitioner SIGNATURE REQUIRED
DOB:
GENDER:
Attending Physician NAME
(if different than ordering)
Routine
Phone:
Pager:
Stat
NOTE: All tests should be MEDICALLY NECESSARY, as supported by the medical record, for diagnosis or treatment, NOT FOR SCREENING
OUTPATIENT requests require Clinical Indications for tests: PLEASE INCLUDE ICD9 CODE(S) FOR SIGN, SYMPTOM, OR DEFINITIVE DIAGNOSIS
@ Indicates Limited Payment Coverage Test
CHEMISTRY
ICD9
HEMATOLOGY
ICD9
THERAPUTIC DRUG TESTING
ICD9
NAB
KKB
CL
CO2
BUN
CREA
GLUC
CA
ALP
ALTO
ASTO
LDB
GGTB
BILDO
BILTO
ALB
AMYB
BNP
CHOL
CKB
HPAB
HDL
IPB
ICA
LDLB
LIPA
HDLT
HDLTB
MGB
MONO
SPEB
BHCG
TP
TRIG
URICB
UHCG
SODIUM
POTASSIUM
CHLORIDE
CO2
BUN
CREATININE
@ GLUCOSE
CALCIUM
ALK. PHOSPHATASE
ALT
AST
LDH
@ GGT
BILIRUBIN, DIRECT
BILIRUBIN, TOTAL
ALBUMIN
AMYLASE
B-TYPE NATRIURETIC PEPTIDE
@ CHOLESTEROL
CREATINE KINASE
H. PYLORI AB
@ HDL (includes total Chol)
INORGANIC PHOSPHORUS
@ IONIZED CALCIUM
@ DIRECT MEASURED LDL
LIPASE
@ LIPID PANEL (80061)
@ LIPID PANEL with MEASURED
LDL (80061 + 83721)
@ MAGNESIUM
MONO TEST
PROTEIN ELECTROPHORESIS
with interpretation
SERUM PREGNANCY TEST
TOTAL PROTEIN
@ TRIGLYCERIDES
URIC ACID
URINE PREGNANCY TEST
THYROID TESTING
CBCP
CBCDP
HCT
HGB
PLAT
WBC
RET
ESR
A1CB
B12
FERI
FOLRB
FOLS
IRBC
IRONB
TRANB
IMMUNOLOGY
ANA MULTIPLEX SCREEN
ANASR ANA MULTIPLEX SCREEN W/REFLEX,
IF POSITIVE WILL INCLUDE: (ORDER SINGLE
FOR KNOWN PATIENTS)
DSDNA,
SMITH,
SM/RNP, RNP,
SS-A/RO,
SS-B/LA,
JO-1, SCL-70, CHROMATIN,
CENTROMERE B, RIBOSOMAL P
ENAB ENA: SSA, SSB, Smith AB, RNP
ANCAB ANCA (titer / pattern if pos), PR3, MPO
ANCA ANCA (titer & pattern if pos)
PR3AB PROTEINASE 3 AB
MPO MYELOPEROXIDASE AB
CRP
C-REACTIVE PROTEIN
RF
RHEUMATOID FACTOR
CEA
@ CEA
EPSA @ PSA SCREEN
PSATM @ PSA DIAGNOSTIC TUMOR MRKR.
IGA
IgA
IGG
IgG
IGM
IgM
ANAS
ICD9
@ TSH - 3rd GENERATION
@ FREE T4 (THYROXINE)
@ FREE TOTAL T3
THYBAT THYROGLOBULIN AB & AG
TSH
FT4
FT3
COAGULATION
PTI
PTT
FIB
LAWUP
PLAB
@ CBC and PLATELETS
@ CBC, DIFF, and PLATELETS
@ HEMATOCRIT
@ HEMOGLOBIN
@ PLATELET
@ WBC COUNT
RETIC COUNT
WESTERGREN SED RATE
@ GLYCATED HEMOGLOBIN
VITAMIN B12
@ FERRITIN
FOLATE, RBC
FOLATE, SERUM
@ IRON, TIBC, TRAN, saturation
@ IRON
@ TIBC & TRANSFERRIN
MONOCLONAL PROTEIN IMM .FIX.
WITH INTERPRETATION; SPECIFY:
QMPRO
SERUM
UMPROP URINE
May include: SPE, QIMM, MPRO, IMFIX,
ICD9
@ PROTIME/ INR
@ PTT
FIBRINOGEN
LUPUS ANTICOAGULANT:
WITH INTERPRETATION
PT, INR, PTT + mix study, TT,
DRVVT, TTCOR, STACLT
ANTICARDIOLIPIN IGG & IGM AB
TP, FLC
@ HIV-1/HIV-2; WBLOT if positive
@ SYPHILIS IGG AB w REFLEX RPR
@ RPR THERAPY RESPONSE ONLY
RUBELLA IGG Immune Status
RUBOIS RUBEOLA Immune Status
VZIS
VARICELLA Immune Status (V. zoster)
HIV
SYPH
RPRT
RUBAG
WEXNER MEDICAL CENTER at
THE OHIO STATE UNIVERSITY
OUTPATIENT LABORATORY REQUISITION
MARCH_2012
(addressograph)
CARB
DIG
LI
PHNO
PTN
THEO
VPA
CARBAMAZEPINE
@ DIGOXIN
LITHIUM
PHENOBARBITOL
PHENYTOIN
THEOPHYLLINE
VALPROIC ACID
HEP1
ACUTE Hepatitis: HBSAG, HBCBG,
HBCBM, HAABM, HCAB
IMMUNE STATUS--Hepatitis: HBCBG,
HBSAB, HCAB
CHRONIC Hepatitis: HBSAG, HBSAB,
HBCBG, HCAB, HBEG, HBEB
HEPATITIS A AB TOTAL
HEPATITIS A AB IgM
HEPATITIS B CORE TOTAL
HEPATITIS B Core IgM
HEPATITIS B SURFACE AB
HEPATITIS B SURFACE AG
with neutralization confirmation if pos
HEPATITIS C AB (with
confirmation if positive)
HEPATITIS TESTING
HEP2
HEP3B
ICD9
HAABG
HAABM
HBCBG
HBCBM
HBSAB
HBSAG
HCAB
URINALYSIS
UAS
UAR
URIN
ICD9
ICD9
URINALYSIS - Dipstick Only
URINALYSIS - reflex to microscopic
URINALYSIS with microscopic
OTHER TESTS
ICD9