Complete Blood Count and Chemistry Requisition Form
This file is a requisition form for various blood count and chemistry tests, including metabolic panels, lipid profiles, and thyroid panels. It is intended to be used by physicians to request necessary lab tests for their patients. The form includes fields for patient and physician information, as well as specific test panels and individual test selections.
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How do I fill this out?
To fill out this form, ensure all blue highlighted sections are completed. Provide accurate patient and physician information, including diagnoses and signatures. Select the required test panels and individual tests before submitting the authorization and attestation section.
How to fill out the Complete Blood Count and Chemistry Requisition Form?
1
Complete all blue highlighted sections.
2
Provide accurate patient and physician info...ppropriate diagnosis codes.
3
Select needed test panels and individual tests.
4
Sign and date the authorization section.
Who needs the Complete Blood Count and Chemistry Requisition Form?
1
Physicians needing to request lab tests for diagnosis and treatment of their patients.
2
Patients who require specific blood count and chemistry tests as prescribed by their physician.
3
Insurance companies needing detailed information to process lab test claims.
4
Lab technicians verifying the necessary details for lab test execution.
5
Healthcare administrators managing patient records and lab test requisitions.
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What are the instructions for submitting this form?
Submit the completed form by mailing it to Alcala Labs, 3703 Camino Del Rio South 100-A, San Diego, CA 92108. Alternatively, fax the form to (619) 450-5870 or submit it online through the lab's submission portal. For queries, contact Alcala Labs at the provided phone number. Ensure that all sections are accurately filled out before submission to avoid processing delays.
What are the important dates for this form in 2024 and 2025?
Ensure to check any updates or renewals of this form for the years 2024 and 2025 to stay compliant with medical regulations.
What is the purpose of this form?
The purpose of this form is to request necessary blood count and chemistry tests for patient diagnosis and treatment. By accurately completing this form, physicians can ensure that lab tests are processed efficiently, allowing for timely diagnostics and treatment plans. It is also used to provide insurance companies with the required details to process lab test claims.
Tell me about this form and its components and fields line-by-line.
- 1. Physician & Practice Information: Provide the physician's and practice's name, address, and contact details. Ensure all required fields are completed.
- 2. Patient Information: Include patient’s last and first name, date of birth, and social security number. Accurate information is crucial for correct lab test processing.
- 3. Diagnosis Codes (ICD 10): Enter the appropriate diagnosis codes related to the patient's condition. It is important for medical necessity verification.
- 4. Panels and Profiles: Select the required blood count and chemistry panels. Options include CMP, CBC, lipid profile, among others.
- 5. Individual Tests: Choose specific tests needed, such as glucose, creatinine, or thyroid-related tests. Ensure the right tests are selected for accurate diagnostics.
- 6. Specimen Information: Provide details about the specimen collected, including date and time of collection and fasting status.
- 7. Authorization & Attestation: Patient and physician signatures are required to authorize the tests and billing. Include any additional necessary authorizations for insurance purposes.
What happens if I fail to submit this form?
Failure to submit this form can result in delayed or denied lab tests and diagnostic procedures, which may affect patient treatment plans.
- Treatment Delays: Without timely test results, necessary treatments may be postponed.
- Insurance Issues: Lack of proper documentation can lead to issues with insurance claims and reimbursements.
- Inaccurate Diagnoses: Incomplete information might lead to incorrect or missed diagnoses, affecting patient health outcomes.
How do I know when to use this form?
- 1. Routine Checkups: Physicians can use this form during routine checkups to request standard blood and chemistry panels.
- 2. Treatment Monitoring: Helps monitor patient response to ongoing treatments by requesting relevant lab tests.
- 3. Diagnosis Confirmation: Used for confirming diagnoses by conducting necessary blood and chemistry tests.
- 4. Pre-surgical Assessments: Ensures patients are fit for surgery by conducting essential blood work and chemistry panels.
- 5. Insurance Claims: Provides necessary information for insurance claims related to lab tests.
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What types of tests can be requested using this form?
The form includes options for various blood count and chemistry tests, such as metabolic panels, lipid profiles, and thyroid panels.
Who needs to fill out this form?
Physicians, patients, and healthcare administrators need to fill out this form to request lab tests accurately.
How can I ensure the form is filled out correctly?
Carefully read and follow the instructions, ensuring all blue highlighted sections are completed and accurate information is provided.
What do I do after filling out the form?
Sign the authorization section, save the completed form, and submit it as required.
Can I edit the form after signing?
Yes, you can edit the form before finalizing it. Ensure all necessary changes are made before saving and submitting it.
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What information is required in the patient and physician sections?
Provide the patient’s name, date of birth, social security number, the physician’s information, signature, and relevant diagnosis codes.
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