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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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.

 

Muscle / Nerve Biopsy Patient Clinical Information Form
Please complete and submit the Muscle/Nerve Biopsy Patient Clinical Information Form with all muscle or nerve biopsy specimens. A Surgical / Cytopathology Requisition should also accompany all muscle or nerve biopsy specimens.

See also the appropriate Tissue Submission Protocol for information regarding specimen collection and handling below:

Renal Biopsy Patient Clinical Information Form
The Renal Biopsy Patient Clinical Information Form may be used to provide the necessary information to allow MLabs to accurately evaluate renal biopsy specimens. See the Renal Biopsy Tissue Submission Protocol for information regarding specimen collection and handling. A Surgical / Cytopathology Requisition should also accompany all renal biopsy specimens.

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.


More information: