Requisition Procedures

The ACL requisition is designed to capture correct information as required by federal or private health care programs and to promote easy, accurate ordering of tests that are reasonable, necessary and supported by the patient record.

  1. Complete a separate test requisition form for each patient.
  2. Record the following:
    • Ordering provider's first and last name and NPI
    • Patient name, date of birth, gender
    • Patient's home phone number, including area code
    • Collection date and time
    • Billing/Insurance information, as necessary (include patient address, insurance plan/number, and policy holder name).
    • Narrative diagnosis, sign or symptom, or ICD-10 code for each test ordered
    • Source of specimens for microbiology and PAP testing
    • Patient address for lead reporting
    • Total volume for 24 hour urine testing (height and weight when clearance is requested)
  3. Mark box(es) with an X indicating the test(s) requested. Use the Comment box to write in test orders for tests not preprinted on the requisition.
  4. The ordering provider should sign the requisition in the upper right corner whenever possible. Should the ordering provider not sign the requisition, order documentation from the patient's medical record MUST be made available to ACL when requested.
  5. Label each specimen with a requisition sticker from top left hand corner of the requisition. Write the patient's full name on the specimen container or tube.
  6. Indicate the type and number of specimens submitted at the bottom of the test requisition in the appropriate box(es).
  7. Submit the top white copy with the specimen(s).
  8. The yellow copy may be sent to ACL Laboratories with the specimen(s) or retained.
  9. The pink copy may be retained for your records.


When ordering laboratory tests for patients who are enrolled in Medicare or other federally funded insurance programs, reimbursement may be limited to:

  1. Only tests that are medically necessary for the diagnosis or treatment of the patient. Federally funded programs may not pay for non-FDA approved tests or tests considered research or investigational use only.
  2. Medicare does not pay for many tests when ordered as screening. Screening test coverage is limited to those tests included in Preventive Services at the defined frequencies.
  3. If there is reason to believe Medicare will not pay for a test, the patient must be informed via the Advance Beneficiary Notice (ABN) of their financial responsibility if Medicare denies payment.
  4. ACL and client customized panels should be ordered only when every component of the customized panel is medically necessary.