Requisition Forms

Third Party Requisition Form (ICD-10)

This requisition form is required on samples drawn Thursday, October 1, 2015 and beyond.

This requisition form is for patients who provide insurance, are covered by Medicare or are self-pay patients.

 

 

 

Client Requisition Form:

t-clientreq
This requisition form is for physician offices that would like to be billed directly (i.e. the physician is billed for services provided).