The DGL requisition is designed to capture correct information as required by federal or private health care programs and to promote easy, accurate ordering of tests that are reasonable, necessary and supported by the patient record.

Use of DGL Test Requisitions

1. Complete a separate test requisition form for each patient.

2. Record the following:
  • Ordering physician's first and last name and UPIN if available
  • Patient name, social security number, date of birth, gender
  • Patient's home phone number, including area code.
  • Collection date and time.
  • Billing/Insurance information as necessary.
  • Narrative diagnosis, sign or symptom, or ICD-9 code for each test ordered.
  • Source of specimens for microbiology testing.
  • Patient address for lead reporting.
  • Total volume for 24 hour urine testing (height and weight when clearance is requested).

    3. Mark box(es) with an X indicating the test(s) requested.

    4. Label each specimen with the patient's full name on the specimen container or tube.

    5. Indicate the type and number of specimens submitted at the bottom of the test requisition in the
    appropriate box(es).

    6. Submit the top white copy with the specimen(s).

    7. The yellow copy may be sent to DGL with the specimen(s) or retained.

    8. The pink copy may be retained for your records.



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