Forms for Collecting Specimens

Clinical Laboratory Specimens

Cytology Specimens

Non-GYN Cytology Specimens

Clinical Laboratory Specimens

Requisition Needed:  Physician Order Form

The Physician Order form for clinical laboratory specimens must be completely filled out prior to submission to the laboratory.  A partially filled out form will result in a delay in processing the specimen.
 
Please include the following information:
• Patient’s full name
• Patient's date of birth
• Telephone number of the specimen collector in the event something is wrong with the specimen or orders
• Requesting Physician (First and Last Name). Nurse Practitioners must provide physician name.
• Diagnosis Code and ICD-9 Format (Highest Specificity)
• Test(s) clearly marked
• Date, time and initials of specimen collection
• Specimen source for non-blood samples
• Insurance provider information MUST be complete on the form, or attach a demographic sheet from the physician office.  The required information form is on the back of the Medicare MSP form.
• Medicare patients MUST complete the MSP form required by Medicare rules.

What do you need to complete for Laboratory Specimen Testing at WakeMed?
• Physician Order Form and a properly labeled specimen
• Insurance provider information (You may attach a face sheet from your patient file.)
• MSP form complete for Medicare Patients

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Cytology Specimens

Requisition Needed:
Laboratory Outreach Services Form for Cytology and Histology specimens.

The Outreach Laboratory form for Cytology specimens form must be completely filled out prior to submission to the laboratory.  A partially fill out form will result in a delay in processing the cytology specimen

• Patient’s full name
• Patient's date of birth
• Date, time and initials of specimen collection
• DIAGNOSIS CODE ICD-9 Format
• Requesting Physician (First and Last Name). Nurse Practitioners must provide physician name.
• Specimens identified  as GYN Cytology ThinPrep Pap
• GYN source specified
• Required information section of order completed
• Insurance provider information MUST be complete on the form or attach a demographic sheet from the physician office.  Medicare patients MUST complete the MSP form required by Medicare rules.

What do you need to complete for Cytology specimen testing at WakeMed?
• Laboratory Outreach Services Form
• Properly labeled specimen containers
• Insurance provider information
• MSP (Medicare form must be completed for Medicare patient)

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Non-GYN Cytology

The Outreach Laboratory form for Cytology specimens form must be completely filled out prior to submission to the laboratory.  A partially filled out form will result in a delay in processing the cytology specimen.

• Patient’s full name
• DOB
• Date, time and initials of specimen collection
• DIAGNOSIS CODE ICD-9 Format
• Requesting Physician (First and Last Name). Nurse Practitioners must provide physician name. 
• Required information section of order completed
• Specimen identity specified
• Insurance provider information MUST be complete on the form or attach a demographic sheet from the physician office.  Medicare patients MUST complete the MSP form required by Medicare rules.

What do you need to complete for non-GYN Cytology specimen testing at WakeMed?
• Laboratory Outreach Services Form
• Properly labeled specimen containers
• Insurance provider information
• MSP (Medicare Form must be completed for Medicare patient)

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Histology Specimens

Requisition:
Laboratory Outreach Services Form for Cytology and Histology specimens
• Patient’s full name
• Patient's date of birth
• Date, time and initials of specimen collection
• Requesting physician (First and Last Name). Nurse Practitioners must provide physician name.
• Clinical history
• Preoperative diagnosis
• Postoperative diagnosis
• Specimens identified as A., B., C., etc.
• Insurance provider information MUST be complete on the form or attach a demographic sheet from the physician office.  Medicare patients MUST complete the MSP form required by Medicare rules.

What do you need to complete for Histology specimen testing at WakeMed?
• Laboratory Outreach Services Form
• Properly labeled specimen containers
• Insurance provider information
• MSP (Medicare form must be completed for Medicare patients.)