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Test Requisitions

Test Requisitions

Test requisitions (PDFs) may also be viewed, printed, and downloaded from our website. If necessary, download Adobe Acrobat Reader. To request printed test requisitions, please contact an Integrated Oncology representative:

Brentwood/Phoenix Clients call 866-875-2271

New York Clients call 800-447-5816

Test Requisition Instructions

Complete the test requisition with all requested information. Ensure all required fields are filled out and information submitted is accurate.

  • Client: account #, name, department, address, ordering physician, phone #, physician/authorized signature
  • Patient: name, gender, DOB, address
  • Billing: insurance company name, policy #, group # (attach face sheet and copy of insurance card)
  • Specimen: hospital status when sample collected, specimen ID #s, body site, collection date and time
  • Clinical: ICD-CM, clinical indication (attach clinical history and pathology reports), clinical status
  • Tests/Services: select tests to be performed

Send a signed, printed copy of the test requisition with your specimens. Please ensure that all information on the test requisition matches the information on the specimens sent (i.e. blocks, slides, tubes).