Can the form be e-signed?

Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. ch. 96) and UETA where adopted. For patient-facing records, provide required consumer disclosures and document consent to electronic delivery when applicable.

Which fields are mandatory?

Essential fields are patient full name, DOB, patient identifier, ordering provider with NPI, tests requested, specimen type, collection date/time, and billing payer or payment indication to avoid processing delays or denials.

What if a specimen is rejected?

The lab should notify the ordering provider with rejection reason and corrective steps. Rejection commonly occurs for labeling errors, insufficient volume, or improper storage.

How long must I keep the order?

Retain orders per HIPAA (6 years, 45 CFR §164.530(j)) and applicable state rules; financial records tied to claims follow IRS minimums (3 years).

Who is authorized to sign?

Ordering clinicians with appropriate credentials (MD/DO/NP/PA) or authorized designees may sign; facility policies determine delegation and attestation requirements.

How do I correct an error on a submitted form?

Follow the lab’s correction policy: annotate and sign amended orders, resubmit via the same secure channel, and document reasons in the patient record to preserve audit trails.

Electronic Signature
Templates
Miscellaneous
Laboratory Request Form

Laboratory Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

LABORATORY REQUEST FORM

Parties and Recitals

Client Name: Client Address:

Laboratory Name: Laboratory Address:

WHEREAS, Client requires laboratory testing, analysis and reporting services as described in this Laboratory Request Form; and

WHEREAS, Laboratory is duly qualified and agrees to perform the requested testing and analysis in accordance with the terms, conditions and specifications set forth herein; and

NOW, THEREFORE, in consideration of the mutual covenants and promises contained in this form, the parties agree as follows.

Request Details

Request Reference / PO Number Requested By (contact) Contact Phone / Email

Scope of Work

Description of Services Requested

Tests and Sample Information

Sample Identification: Sample Type:

Collection Date: Collection Time: Collected By:

Chain of Custody / Special Handling Instructions Tests Requested (check applicable)

Microbiology / Culture Chemistry / Quantitative Molecular / PCR Toxicology

Other Tests / Details

Billing and Payment Terms

Agreed Fee (per sample or flat): $ Billing Party:

Payment Schedule

Late Payment Fee: Billing Contact:

Turnaround Time & Reporting

Standard Turnaround Time: Report Delivery Method:

Special Reporting Requirements

Term and Termination

Effective Date: Expiration Date:

Termination Notice Period

Either party may terminate this request for cause upon written notice if the other party materially breaches any obligation and fails to cure within the notice period specified above. Termination does not relieve Client of the obligation to pay for services performed or costs reasonably incurred prior to termination.

Confidentiality

Laboratory shall treat all samples, test results, technical information and client-supplied data as confidential and shall not disclose such information to third parties except (a) as required by law, (b) to contractors necessary to perform the testing under a written confidentiality obligation, or (c) with Client's prior written consent. Laboratory will implement reasonable safeguards to protect confidentiality consistent with industry practice.

Liability, Acceptance and Warranties

Laboratory warrants that services will be performed in a professional manner consistent with applicable laboratory standards. Except as expressly set forth in this form, Laboratory makes no other warranties, express or implied. Client acknowledges that laboratory testing is subject to limitations and uncertainties; Client is responsible for providing accurate sample information and for interpreting results in context. Except for gross negligence or willful misconduct, Laboratory's aggregate liability for direct damages arising out of or related to the services shall be limited to the fees paid by Client for the specific services giving rise to the claim.

Acceptance Criteria and Sample Rejection

Laboratory reserves the right to reject samples that do not meet specified acceptance criteria (e.g., improper container, insufficient volume, compromised integrity). Laboratory will notify Client of rejection and, if requested and practicable, attempt to arrange recollection at Client's expense. Client remains liable for charges associated with initial processing and reasonable disposal where applicable.

Governing Law

This Agreement shall be governed by and construed in accordance with the substantive laws of the state selected by the parties. Parties agree that jurisdiction and venue for any dispute shall lie in the courts of that state unless the parties agree otherwise in writing.

Entire Agreement

This Laboratory Request Form, together with any attachments, test specifications and approved change orders, constitutes the entire agreement between Client and Laboratory with respect to the services described herein and supersedes all prior proposals, representations and agreements, whether oral or written. Any modification must be in writing and executed by authorized representatives of both parties.

Authorizations and Certifications

The undersigned certifies that they have authority to request the services described and to bind the party on whose behalf this request is made. Client authorizes Laboratory to proceed with the requested work under the terms of this form.

Additional Instructions / Notes

Client:

By:

Date:

Laboratory:

By:

Date:

What the Laboratory Request Form Is and When It’s Used

A Laboratory Request Form is a standardized document used by clinicians, laboratories, and healthcare facilities to authorize specimen collection, identify the tests to be performed, and provide clinical, billing, and patient-identifying information required for accurate processing. It connects the ordering provider, patient, and laboratory by recording test codes, diagnosis (ICD-10) indications, specimen type, collection date/time, and any special handling or transport instructions. The form supports chain-of-custody, billing, and clinical decision workflows and is commonly integrated with EHRs, lab information systems, and eSignature platforms to reduce transcription errors and speed turnaround.

Why a Well-Prepared Laboratory Request Form Matters

A complete, accurate form reduces sample rejections, accelerates result turnaround, and minimizes billing and compliance risk by ensuring the lab has clear clinical justification and correct patient identifiers.

Who Typically Prepares and Signs This Form

Common users include ordering clinicians, nursing staff, laboratory accessioning teams, and billing specialists.

Physicians, nurse practitioners, and physician assistants who order diagnostic tests and supply clinical indications.
Laboratory accessioning and phlebotomy teams who verify specimens, label tubes, and record collection details.
Billing and administrative staff who confirm insurance, billing codes, and patient demographics for claims processing.

Clear role separation — ordering provider for clinical content, lab staff for specimen handling, and billing teams for payment information — improves accuracy and compliance.

Essential Sections That a Professional Form Should Include

A professional Laboratory Request Form groups information into clinical, administrative, and logistical blocks so every party can find and verify required details quickly.

Patient Details

Full legal name, date of birth, patient ID/MRN, and contact information for identification and match to records.

Ordering Provider

Provider name, NPI, facility, contact phone, signature, and credential to validate clinical authorization.

Tests Requested

Clear test names, CPT/LOINC codes where applicable, priority level, and clinical ICD-10 diagnosis codes that justify testing.

Specimen Details

Specimen type, collection date/time, labeling information, volume, and any special handling or transport conditions.

Billing Information

Insurance payer, subscriber ID, billing account, and indication of who will be billed (patient, provider, or facility).

Special Instructions

Fasting status, STAT requests, chain-of-custody notes, or any patient-specific precautions for collection or transport.

Step-by-Step: Completing and Submitting the Form

Follow these steps to ensure the order is complete and the specimen is processed without avoidable delays.

01

Prepare Order: Confirm clinical indication, tests, and billing party before starting the form.
02

Verify Patient: Match identifiers and DOB to the medical record and patient ID band if collecting in person.
03

Collect Specimen: Label tubes at bedside, record collection date/time, and follow handling instructions.
04

Submit to Lab: Send form with the specimen via EHR, secure portal, courier, or approved fax depending on lab policy.

Where the Form Goes and What Happens Next

Understanding the routing steps helps you anticipate processing, accessioning, and reporting milestones.

Accessioning: Lab receives form and specimen, assigns accession number, and verifies required fields.
Testing: Specimen is routed to appropriate instrument or reference lab based on test and priority.
Verification: Laboratory technologist reviews results, performs QC, and validates before release.
Reporting: Results are released to ordering provider via EHR, secure portal, or fax as configured.

Configuring an Electronic Workflow for the Form

When adapting the form for online completion, configure fields, authentications, and integrations to match clinical and billing workflows.

Field	Configuration
Authentication Method	Email link, SMS code, or organization SSO for signer verification
Auto-mapping	Map fields to EHR/LIS to reduce duplicate entry and transcription errors
Conditional Fields	Show CPT/ICD fields only when test requires clinical justification
Attachments	Permit clinical notes, prior results, or scanned ID as required

Digital Submission Requirements and Integration Notes

Use secure systems that meet healthcare compliance standards and integrate with clinical systems.

EHR / LIMS: API access for integration
Storage & Security: AES-256 at rest
Third-party Integrations: Connectors for Microsoft 365 and Google Workspace

Timelines and Time-Sensitive Expectations

Time windows matter for specimen viability, billing, and clinical decision-making. Confirm specific test instructions with the performing laboratory.

Specimen Viability Window:

Varies by assay; common ranges 24–72 hours refrigerated; check lab instructions

Accessioning Targets:

Lab should accession and process within the lab’s published turnaround windows

STAT vs Routine:

Mark STAT orders clearly; STAT reduces queueing but follows lab priority rules

Result Turnaround:

Turnaround depends on test complexity; rapid tests return same day, reference tests longer

Billing Deadlines:

Submit claims per payer deadlines; timely filing limits vary by payer

Consequences of Incomplete or Incorrect Forms

Sample Rejection: Missing or wrong identifiers risk sample rejection

Delayed Diagnosis: Incorrect handling or late receipt delays clinical care

Billing Denials: Missing ICD-10/CPT triggers payer denials

Compliance Fines: HIPAA breaches risk regulatory penalties

Chain-of-Custody Loss: Poor documentation can invalidate forensic or legal testing

Patient Safety: Mislabeling or wrong-site collections can cause harm

Practical Tips for Accurate and Efficient Completion

Adopt consistent verification and electronic practices to reduce errors and speed processing across clinical and administrative teams.

Verify two patient identifiers

Use two unique identifiers (name plus DOB or MRN) at collection to prevent misidentification; cross-check with EHR before labeling tubes.

Include clinical justification

Enter clear ICD-10 codes and brief clinical notes to justify tests and reduce payer denials for non-routine or high-cost assays.

Label at bedside

Label specimen containers in the patient’s presence and record collection time to preserve chain-of-custody and specimen integrity.

Prefer electronic submission

Use secure EHR or lab portal uploads to eliminate handwriting errors, ensure audit trails, and accelerate accessioning and reporting.

Real-World Examples of Electronic Form Use

Organizations across healthcare and specialty clinics use digital workflows to reduce administrative friction and preserve compliance.

Fertility Centers of Illinois

Their clinic moved consent and specimen requests online to reduce patient wait times and manual entry.

Implementation linked forms to the EHR for automatic population of identifiers.
The team reported strong satisfaction with vendor support and reliable API integration, enabling faster patient throughput while maintaining PHI controls tied to audit trails and access logs.

Martin Properties (mobile clinics)

A mobile health unit standardized lab request forms for onsite testing and remote reporting.

The solution supported offline completion and later sync when connectivity returned.
Field staff could collect samples, capture patient identity, and submit orders securely once back in network range, reducing processing delays common to paper forms.

Comparing eSignature Options for Laboratory Request Forms

Evaluate price, HIPAA support, bulk send capability, and audit features when choosing an eSignature provider for laboratory workflows.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Trial available	Trial available	Trial available	Trial available
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs and Troubleshooting for the Laboratory Request Form

Answers to common operational and compliance questions encountered when preparing, submitting, and storing laboratory orders.

Need help? Contact support

Can the form be e-signed?
Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. ch. 96) and UETA where adopted. For patient-facing records, provide required consumer disclosures and document consent to electronic delivery when applicable.
Which fields are mandatory?
Essential fields are patient full name, DOB, patient identifier, ordering provider with NPI, tests requested, specimen type, collection date/time, and billing payer or payment indication to avoid processing delays or denials.
What if a specimen is rejected?
The lab should notify the ordering provider with rejection reason and corrective steps. Rejection commonly occurs for labeling errors, insufficient volume, or improper storage.
How long must I keep the order?
Retain orders per HIPAA (6 years, 45 CFR §164.530(j)) and applicable state rules; financial records tied to claims follow IRS minimums (3 years).
Who is authorized to sign?
Ordering clinicians with appropriate credentials (MD/DO/NP/PA) or authorized designees may sign; facility policies determine delegation and attestation requirements.
How do I correct an error on a submitted form?
Follow the lab’s correction policy: annotate and sign amended orders, resubmit via the same secure channel, and document reasons in the patient record to preserve audit trails.

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