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Outside of Alberta Test Requisition FormLab Use on

Outside of Alberta Test Requisition FormLab Use on

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[Music] when starting the form please review your account information in box one in box two please fill out your patient or your client's information in the blue highlighted areas followed by their signature and today's date in box 3 please fill out the billing information in box 3 you will have the option to choose to be billed directly to your facility if you would like to choose this option a supervisor signature will be required if your patient or client is in a grant program covered under state or federal grant please provide the program name for all other patients or clients a valid active health insurance plan must be provided for the test to be performed [Music] [Music] [Music] in box 4 please enter all necessary icd-10 diagnosis codes along with checking the box next to the correct drug panel or enter any additional tests below lastly in box 5 please have the ordering physician or provider sign on the first line next to the x followed by the specimen collector&

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