This requisition may be used by Pathologists or other physicians to accompany specimens (e.g., bone marrow, peripheral blood, fresh tissue, body fluid) sent for Hematopathology consultation. Please use the Anatomic Pathology Consultation Requisition when sending only slides and/or blocks.

This requisition is used for immunohistochemistry tech-only.

This document lists (Michigan Only) insurances for laboratory services. Laboratory testing benefits, copays, referral and prior authorization requirements may vary by individual policy.

This requisition can be used for sending testing performed by the Michigan Center for Translational Pathology (MCTP) Molecular Testing Laboratory, which includes PCA3, MPS (MyProstateScore), and Circulating Tumor Cells by CellSearch.

A signed Advance Beneficiary Notice of Non-coverage (ABN) form must accompany any samples sent for PCA3 or MPS testing from Medicare patients when MLabs will be billing Medicare or the patient.

This requisition should accompany specimens sent for BRCA testing performed by the Michigan Medical Genetics Laboratories (MMGL) Molecular Genetics Laboratory.

This requisition should accompany specimens sent for testing performed by the Michigan Medical Genetics Laboratories (MMGL) Molecular Genetics Laboratory.

This requisition includes an expanded menu of Molecular Diagnostics assays. Complete and submit this form with all requests for the Cystic Fibrosis Mutation Detection or other molecular diagnostics assays.

The molecular services brochure covers details about our genetic, molecular oncology and translational services.