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Laboratory Test Request Form

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LABORATORY TEST REQUEST FORM

RECITALS

WHEREAS, Requesting Party: desires laboratory testing services for clinical, research, or diagnostic purposes; and

WHEREAS, Laboratory Provider: is duly qualified, accredited, and capable of performing the requested analyses in accordance with applicable standards and accepted industry practice; and

WHEREAS, the parties intend that this form serve both as an authorization to perform tests and as an agreement recording the scope, payment, confidentiality, and other material terms governing the provision of testing services.

REQUESTING PARTY INFORMATION

Phone:

Email:

ORDERING PROVIDER / AUTHORIZED SIGNER

License/ID:

Phone:

Fax:

PATIENT / SUBJECT INFORMATION

DOB (MM/DD/YYYY):

Sex:

Patient ID / MRN:

SPECIMEN / COLLECTION DETAILS

Specimen Type (check all that apply):

Collection Date (MM/DD/YYYY):

Collection Time:

Collector Name:

TESTS REQUESTED

Indicate each test required. Tests will be performed using the laboratory's standard validated methods unless a specific method is specified and accepted in writing by the laboratory.

CLINICAL INFORMATION

Provide relevant clinical history, provisional diagnosis, and indications for testing. Accurate clinical information is necessary for appropriate test selection, interpretation, and reporting.

CHAIN OF CUSTODY & COLLECTION CERTIFICATION

The collector certifies that specimens were collected, labeled, stored, and transported in accordance with applicable protocols and that the information provided is true and complete to the best of their knowledge.

Collector Signature:

Date Signed:

PAYMENT TERMS

The Requesting Party agrees to pay the Laboratory for services rendered under the following terms. Charges are based on the Laboratory's established fee schedule and any quoted estimates are non-binding for tests added or changed after submission.

Late payments shall accrue interest at the rate of on overdue balances, and the Laboratory may suspend testing and withhold results until outstanding amounts are settled. The Requesting Party remains obligated to pay for all tests performed prior to suspension or termination.

SCOPE OF WORK

The Laboratory shall perform the specific analyses requested on the submitted specimens and shall report results in written or electronic form consistent with the Laboratory's reporting practices. Deviations from requested methods must be approved in writing by the Requesting Party when such deviations materially affect results.

TERM AND TERMINATION

This authorization and agreement shall become effective on Start Date: and shall continue until End Date: unless earlier terminated by either party upon days' written notice. Termination does not relieve the Requesting Party of liability for tests performed or costs incurred prior to termination.

CONFIDENTIALITY

Each party shall maintain as confidential all non-public information received from the other party in connection with this request, including patient identifiers and test results, and shall not disclose such information except as required by law or as necessary to perform the services described herein. The Laboratory may disclose results to authorized healthcare providers and payors as necessary for treatment and billing.

GOVERNING LAW

This form and any dispute arising out of the services to be provided hereunder shall be governed by and construed in accordance with the substantive laws of the jurisdiction in which the Laboratory conducts testing, without regard to conflict of laws principles. Parties consent to the exclusive venue of courts located within that jurisdiction.

ENTIRE AGREEMENT

This document, together with any attachments and written confirmations, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings, agreements, representations and warranties, whether written or oral.

AUTHORIZATION & CERTIFICATION

By signing below, the Ordering Provider certifies that they are authorized to order the requested tests, that informed consent has been obtained where required, and that the information provided on this form is accurate. The Requesting Party authorizes the Laboratory to perform the tests and to bill the designated responsible party.

Requesting Party Printed Name:

By:

Date:

Laboratory Representative Printed Name:

By:

Date:

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What the Laboratory Test Request Form Is and when it’s used

A Laboratory Test Request Form is a structured requisition used by clinicians, clinics, and authorized facilities to order clinical laboratory analyses, document patient identifiers, capture specimen details, and record test-specific instructions. The form establishes chain-of-custody and billing information, signals required handling or transport conditions, and creates a permanent record for clinical and regulatory review. Accurate completion reduces specimen rejection, supports timely results, and ensures the laboratory has the patient consent and clinical context necessary to perform and report tests safely and compliantly.

Why a correct Laboratory Test Request Form matters

Using a complete, standardized form reduces processing delays, prevents rejected specimens, and documents clinical intent and consent. It protects patient safety by communicating collection instructions and preserves legal traceability for reporting, billing, and quality assurance purposes.

Why a correct Laboratory Test Request Form matters

Who typically completes or receives this form

The form is completed by authorized clinicians, nurses, phlebotomists, or ordering staff before specimen collection and sent to the performing laboratory.

  • Clinics and physicians’ offices sending samples to reference labs.
  • Hospital departments coordinating in-house lab work and chain-of-custody.
  • Public health units and reporting entities submitting notifiable test orders.

Receiving laboratories, laboratory information systems (LIS), and billing teams use the completed form to route, process, and retain test records according to clinical and regulatory requirements.

Typical signers and approvers

Ordering Provider

Physician, nurse practitioner, or authorized clinician who documents clinical indication, signs the requisition as the authorized medical order, and ensures informed consent if required by law.

Laboratory Technician

Phlebotomist or lab staff who documents specimen collection details, verifies patient identity at collection, and initials the form to confirm chain-of-custody and sample integrity.

Essential sections every professional form should include

A well-designed Laboratory Test Request Form groups clinical, identification, specimen, billing, and administrative data so labs can accept, prioritize, and report results without follow-up questions.

Patient ID

Full legal name, date of birth, medical record number, and a second identifier like SSN or patient ID.

Clinical Information

Diagnosis code or reason for test, relevant clinical notes, and ordering provider details.

Specimen Details

Specimen type, collection date/time, container type, special handling, and volume.

Test Selection

Exact test names and CPT or internal test codes to avoid ambiguity.

Consent & Authorization

Patient consent for testing and disclosure, signature or electronic consent indicator.

Billing & Shipping

Billing party, insurance or account number, and courier instructions for transport.

Step-by-step: complete and submit the test request

Follow these ordered steps to ensure specimens are accepted and tests completed without administrative delay.

  • 01
    Prepare patient: Verify identity and explain the test purpose and consent.
  • 02
    Complete form: Fill all required fields and use standard test codes.
  • 03
    Collect specimen: Follow collection and labeling protocols immediately after filling form.
  • 04
    Transmit to lab: Send form and sample with correct shipping and billing instructions.

How electronic submission and lab routing typically work

Electronic workflows replace paper handoffs and capture an audit trail for each step from order to result.

  • Upload: Sender uploads requisition and attaches clinical notes.
  • Assign fields: System maps test codes to lab panels automatically.
  • Notify lab: Lab receives order with specimen pickup details.
  • Track: Audit trail logs timestamps, user, and actions.

Common digital workflow settings for online forms

Configure these settings to automate routing, authentication, and notifications for each Laboratory Test Request Form.

Field Configuration
Auto-populate patient Enable from EHR integration or CSV import
Signer authentication Use email, SMS code, or stronger verification
Conditional fields Show handling instructions based on test type
Notification Email or system alert to lab on submission

Technical considerations for secure eSubmission

Choose a platform that supports secure file formats, audit trails, and integrations with LIS or EHR systems.

  • File formats: PDF and DOCX supported
  • Integrations: EHR and LIS connectors
  • Security: TLS and AES encryption

Confirm platform supports HIPAA BAA, role-based access, and exportable audit logs to meet clinical and legal retention requirements.

Data elements and security flags to include

Patient ID: Name and DOB
Specimen ID: Unique sample code
Ordering Provider: Clinician name
Consent Status: Signed or electronic
Handling Notes: Temperature or biohazard
Billing Info: Account or insurer

Common mistakes that cause delays or rejections

  • Incomplete patient identifiers—omitting DOB or an ID number commonly triggers specimen hold or rejection and requires recollection.
  • Ambiguous test names—writing nonstandard test descriptions forces lab staff to query the ordering provider and delays results.
  • Incorrect collection times—missing or inaccurate timestamps invalidate time-sensitive assays or alter interpretation.
  • Missing consent or signature—tests requiring explicit authorization are held until valid consent is obtained, delaying processing.

Regulatory and operational risks of improper forms

Patient safety: Misidentification risk
Testing errors: Wrong test performed
HIPAA violations: Unauthorized PHI disclosure
Billing audits: Claim denials risk
Public health reporting: Late notifiable disease reports
Legal exposure: Malpractice or compliance fines

Typical timing expectations and processing windows

Track time-sensitive steps: specimen stability, lab turnaround, and reporting deadlines to ensure clinical usefulness and compliance.

Specimen stability:

Follow manufacturer's acceptable time/temperature limits

Lab turnaround:

Stat tests often 1–4 hours; routine tests 24–72 hours

Notifiable reporting:

Report public health results per state timelines

Retests:

Collect repeat samples within required window

Billing submission:

Submit claims per payer deadlines

Key milestones from order to result

A concise milestone sequence helps staff monitor progress and escalate exceptions promptly.

01

Order Entry

Requisition completed and transmitted.

02

Specimen Collection

Sample collected and labeled at point of care.

03

Transport & Receipt

Courier delivers and lab logs specimen.

04

Analysis & Reporting

Testing performed and results released.

How a Test Request differs from related documents

Compare the Laboratory Test Request Form with similar documents to choose the correct form for clinical, legal, and billing needs.

Document Type Test Requisition Consent Form
Primary Purpose order specimen authorize procedure
Signature Required often yes always yes
PHI Included
Legal Weight clinical order legal consent

eSignature vendor pricing and capability snapshot relevant to form signing

Below is a concise comparison of starting price and key capabilities for common eSignature providers; signNow is listed first per the pricing data.

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 Free trial available Free trial available Free trial available Free trial available
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Real-world examples of digitizing clinical forms

Two customer examples illustrate how online signing and templates streamline clinical paperwork and specimen workflows.

Fertility Centers of Illinois

Implemented electronic forms to collect patient consents and test orders quickly

  • Reduced patient follow-up and phone confirmations
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Optica Ventures LLC

Adopted digital requisitions to standardize sample submissions across clinics

  • Improved data consistency and reduced missing identifiers
  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

Frequently asked questions and troubleshooting tips

Answers to common questions about completion, electronic signatures, consent, and retention for Laboratory Test Request Forms.


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