Lab Form_General Requisition Form General
User Manual: LabForm_General-Requisition
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THE NATIONAL WOMEN’S HORMONE LABORATORY
DRAW AND SEND SPECIMEN TO:
6901 Mercy Rd. Omaha Ne 68106
Phone: 402-390-0532 Fax: 402-505-8931
CLIA # 28D043756
Thomas W. Hilgers M.D. Medical Director
Thomas W. Hilgers M.D. Laboratory Director
PATIENT INFORMATION
Name (Last, First)________________________________________________ Date of Birth____/____/_______
Address________________________________________________________ Phone_____-_____-_______ Gender MALE / FEMALE
PPVI Account #____________________ *****NEW PATIENTS MUST SEND DEMOGRAPHIC INFORMATION FOR PROCESSING*****
BILLING INFORMATION
Bill To: Patient Self-Pay / Insurance* / Client *SEND COPY OF INSURANCE CARD (front and back)
Insurance__________________________________________ Ordering Provider________________________________________
Subscriber ID_________________ Group #_______________ Provider Phone #_____-_____-_______ Fax # _____-____-______
Name of Policy Holder _______________________________ Signature of Provider (Required)____________________________
ORDER INFORMATION
Patient on HCG: Y/N
Last Menstrual Period___-___-_____ Cycle Day ____or Peak + _______ OB ETA ___-____-_____ by : US LMP PEAK DAY
Gestational Weeks _______Days____
DATE DRAWN____________TIME DRAWN______________INITIALS_________Facility _________________ Phone ____-____-______
□ 84144 PROGESTERONE □ 82157 ANDROSTENEDIONE □ 84443 TSH □ 83001 FSH
□ 82670 ESTRADIOL □ 82627 DHEA-SO4 □ 84439 FT4 □ 83002 LH
□ 84270 SHBG □ 84480 T3 □ 84146 PROLACTIN
□ 84403 TOTAL TESTOSTERONE □ 84436 T4
□ 84702 HCG Quantitative
DRAWING INSTRUCTIONS
Draw blood into a red top tube or SST/Tiger Top
Let specimen clot and spin for 15 minutes (or follow your labs procedure for collecting serum)
Submit a minimum of 2 mL serum in an aliquot tube. Label with the patients NAME/DOB/DATE. **DO NOT SEND IN SST**
Progesterone, Estradiol and HCG may be room temperature for < 5days, ALL other tests must be sent on ICE PACKS for next day delivery
Prepaid shipping kits are available for purchase, please call 402-390-0532 to order a kit
DIAGNOSIS
Diagnosis is MANDATORY for all Patient and Insurance Billing. Please circle the appropriate Diagnosis.
N93.9 Abnormal Uterine Bleeding
N91.2 Amenorrhea
E28.8 Hyperhormonal
N91.0 Primary
N91.1 Secondary
N91.0 Anovulation
E23.6 Anterior Pituitary Disorders
N94.6 Dysmenorrhea
N94.4 Primary
F45.8 Psychogenic
N94.5 Secondary
N96 Habitual SAB (Hx of)
N92.5 Irregular Menstruation, Other
E34.9 Low Progesterone
E28.9 Luteal Phase Defect
E28.8 Late Luteal Defect
N91.1 Metrorrhagia
N92.4 Menopausal
O72.1 Postpartum
N92.4 Premenopausal
F45.8 Psychogenic
E28.2 Polycystic Ovaries
Z34.90 Pregnancy, Normal # Wks_____
O09.891 Pregnancy High Risk # Wks____
Z32.00 Pregnancy Test, Result unknown
N94.3 Premenstrual Tension Syndrome
E03.9 Hypothyroidism, NOS
E05.90 Hyperthyroidism, Unspecified
Z13.29 Thyroid Disorder Screening
R53.83 Fatigue, Other
N80.9 Endometriosis, Unspecified
N71.1 Endometritis, Chronic
E28.39 Other Primary Ovarian Failure
Other Diagnosis________________
STANDING ORDER
DATE OF ISSUE:____________
DATE OF EXPIRATION:___________
