How to Complete the Requisition

Follow the simple steps outlined below to ensure your requisition is completed accurately. For additional tips, please also review the "Required Info" section below.

Completing the Requisition

Thank you for beginning the test kit submission process. Our test requisition form gathers everything we need to know in order to:

  • Process your selected test
  • Bill the responsible party
  • File a claim for reimbursement, if applicable

You may click on the images to enlarge them for easy viewing or select the Download option below and print them.

Front -
Requistion Form Sample
Back -
Requistion Form Sample
Download PDF

Required Information

Use the handy chart below to determine what information is required with the submission of your requisition.

Once you've completed the requisition, selected your billing option, and verified that all required information has been provided, you're ready to send your kit back to the lab!

Requirements for All Requisitions

  • Billing Options
  • Patient Demographics
  • Responsible Party Acknowledgment Signature

Requirements for Specific Billing Methods

Billing Method Chosen Diagnosis Code Primary Insurance Information Payment Information
Bill Practitioner Not Required Not Required Not Required
Bill Medicare Required Required Not Required
Bill Insurance (EasyPay) Required Required Required
No Insurance Billing Not Required Not Required Required

If required information is not provided, it could result in disqualification from our billing program. Additionally, by default, the patent could receive a bill for up to the list price or the ordering physicians account could be billed for the testing provided.

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