HealthEast Medical Laboratory Requisition Form

Thank you for choosing HealthEast Medical Laboratory.

If you are submitting this form fewer than 12 hours before collection time, please call our customer service at 651-232-3500.

If you are seeking Medicare reimbursement, order only tests that are medically necessary.

Yes
No
Collection center number
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Facility Name
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Completed by
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Email address
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Phone number
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Patient first name
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Patient middle initial
Patient last name
*
Patient date of birth (xx/xx/xxxx)
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Male
Female
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Yes
No
If yes, enter patient's address
Medicare number
Room number
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Unit name
Chart number
Physician name (last, first)
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Single request
Cancel single request
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Date of draw (xx/xx/xxxx)
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Basic Profile (BMP)
BUN (BUN)
Calcium (CA)
Creatinine (CRE)
Electrolytes Profile (LT4)
Glucose (GLU)
Glycosylate Hgb (A1C)
Hepactic Profile (LFT)
Potassium (K)
Renal (RFP)
Sodium (NA)
TSH (TSH)
Hct (HCT)
Hemogram 1 with Diff and Plt (HM1)
Hemogram 2 with Plt - no Diff (HM2)
Hgb (HGB)
INR (INR)
Platelet (PLT)
Sed Rate (ESR)
WBC (WBC)
WBC with Diff (WBC, ADF)
Blood Culture (BC)
Carbamazepine (CAR)
Digoxin (DIG)
Dilantin (DLN)
Other lab procedures
Please indicate the diagnosis code(s) for each lab procedure selected above. Your request will not be honored without a diagnosis code indicated for each test.
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