Forms

REQUISITION FORMS – REQUIRED INFORMATION

1)         Name of requesting physician.

2)         Full name of patient, clearly and correctly spelled.

3)         Patient’s SSN or MRN (strongly requested).

4)         Patient’s sex and date of birth.

5)         Date of specimen collection.

6)         Patient’s address.

7)         Attach copy of insurance card (front and back).

8)         ICD-9 code(s).

9)         Exact anatomic source of specimen and test(s) requested.

10)       Pertinent patient history and clinical information.

PAC RIM MASTER REQUISITION FORM
Pac Rim IHC Requisition Form
Pac Rim Pregnancy Loss and NIPT Requisition Form
PAC RIM SPECIMEN LABELING AND REQUISITION COMPLETION INSTRUCTIONS