Patient Information Forms

To ensure accuracy and completeness of the result, certain testing must be accompanied by various patient information forms in addition to the MLabs requisition or electronic order. Information regarding the tests performed by our laboratories as well as proper sample collection, handling and storage information and whether a specific form is required can be found in the MLabs Test Catalog.

 

Add-On Test Request Form
This form is used to authorize additional testing be performed on a specimen already at MLabs for which we do not already have a written order. According to CLIA regulation # 493.1105, MLabs must receive written authorization from a client within 30 days of a verbal request.                         

Michigan Department of Community Health Blood Lead Analysis Form
Complete the first three sections of this form and submit with specimens sent for Lead, Blood, or Heavy Metal Screen, Blood, analysis.

MLabs Patient Demographics Form
This form can be used to provide patient demographics for patient or insurance carrier billing.

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Molecular Diagnostics – Clinical History Form
Effective September 4, 2018, MLabs will require that all requests for molecular tests are accompanied by the MLabs Molecular Diagnostic Clinical History Form AND a recent pathology report, relevant clinic encounter notes, or medical genetics consultation.

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Revised Diagnosis Request Form
This form can be used to provide or revise ICD-9 or ICD-10 code(s) submitted for insurance carrier billing.

UMHS Request and Consent for Genetic Testing
The ordering clinician or an individual to whom the clinician has delegated authority is required by Michigan law to obtain the written informed consent of the test subject for presymptomatic or predictive genetic testing. By ordering such genetic testing from MLabs the clinician acknowledges that informed consent has been obtained from the patient as required by applicable state or federal laws and the ordering clinician has authorization from the patient permitting MLabs to report the test results to the ordering clinician.


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