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Test Request Form Overview

The Test Request Form (TRF) has been updated for 2023 and is considered an official order form that must be completed fully and accurately to ensure seamless and timely processing and delivery of test results.TRFs are included with each specimen collection kit shipped from the laboratory and can be found among all the items necessary for collecting and providing a specimen, along with provisions for payment.

PROVIDERS are responsible for filling out the top four sections of the TRF highlighted in BLUE.

PATIENTS are responsible for filling out the remaining TRF sections highlighted in YELLOW.

Guidelines for Filling Out the Test Request Form

 

A couple of patients reviewing their statement.

Provider Responsibility Sections
Top Area of Form

  1. The correct provider's name and NPI must be filled in. Provider must sign, unless marked  >signature on file< , and date the Test Requisition Form. See Electronic Signature Authorization Form for details.
  2. Check the desired Billing Type (only select one).
  3. If the Billing Type is Insurance or Medicare, ICD-10 codes must be provided.
  4. Select the test you are ordering – confirm your selection is correct.

 

A couple of patients reviewing their statement.

Patient Responsibility Sections
Bottom Area of Form

  1. Please fill out all patient information correctly.
    DO NOT SKIP * Date Sample Collected!
  2. Fill out all insurance information, including the claim address found on the back of your insurance card(s). Please include a copy of the front and back of insurance card(s).
  3. Patient/Responsible Party Acknowledgement must be filled out completely and signed to avoid delays in processing.
  4. Credit Card Payment Authorization must be filled out completely and signed to avoid delays in processing.

 

Sample Test Request Form

Questions? Contact our customer service professionals for help at 877.485.5336.