Dianon
Test Requisitions
To request printed test requisitions, please contact our client services department at 800-328-2666.
- 1107 GI EGD (PDF)
- 1361 Gynecology (PDF)
- 711 Hematology Oncology (PDF)
- 1376 Urology (PDF)
- 260N Urology (PDF)
- 1192 Ambulatory Surgery Center (PDF)
- 1190L Dermatopathology (PDF)
- 1193 Endocrinology (PDF)
- 1350A GI Pathology (PDF)
- 1350T GI Pathology (PDF)
- 1369 GI Pathology (PDF)
- 1369C GI Pathology (PDF)
- 1121 Lower GI (PDF)
- 1376T Urology (PDF)
- DN 1437 Breast (PDF)
- 261N Patient Support Services (PDF)
- 0300D Dermatopathology (PDF)
Test Requisition Instructions
Complete all required fields on test requisitions. Ensure that all required fields are filled out and the information submitted is accurate.
- Client: Account #, name, department, address, ordering physician, phone #, physician/authorized signature
- Patient: Name, gender, DOB, address
- Billing: Insurance company name, policy #, group # (attach face sheet and copy of insurance card)
- Specimen: Hospital status when sample collected, specimen ID #s, body site, collection date and time
- Clinical: ICD-10-CM, clinical indication (attach clinical history and pathology reports), clinical status
- Tests/Services: Select tests to be performed
Send a signed, printed copy of the test requisition with your specimens. Please ensure that all information on the test requisition matches the information on the specimens sent (i.e., blocks, slides, tubes).