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Forms and Requisitions

Important Note

Click on the links below.

Note: These are all pdf files and may have to be downloaded to view.

Forms & Requisitions

FORMS

 

ORDERS: 

RESULTS: 

SUPPLIES/OFFICE INFO

COREWELL HEALTH Employees and Sites

SUPPLIES/OFFICE INFO

Independent, Non-Corewell Health West Offices

BILLING: 

CONSENT: 

HIV Consent Form

Genetic testing

REQUISITION/PAPER ORDERS**

See important note below table
General Laboratory Requisition 
Advanced Technology Laboratory (ATL)
Allergen Specific IgE Testing
Anatomic Pathology (AP)
COVID19 SARS-COV2
Cystic Fibrosis (CF) Test
Infectious Disease (Microbiology)
Pediatric Blood Lead Testing
Peritoneal Dialysis Labs
Phone Order
Quad Form 
Stain Worksheet for AP Testing
Surgical Specimen Testing by ATL
SHMG/SH Epic Downtime Requisition

**IMPORTANT NOTE: The following information is required on all laboratory requisitions, failure to provide this information may result in delay of results or possible specimen cancellation and request for recollection

 

Patient Information 

  • Full name (legal name) including middle initial
  • Birth Date
  • Address and Phone Number

Billing Information

  • Policy holder name
  • Policy holder address
  • Insurance name, address, and type
  • Contract, Plan or Group Numbers
  • Policy holder’s employer
  • Relationship to patient
    • Note: A copy of patient’s insurance card (front and back) is advised.

Provider Information 

  • Ordering and Attending Provider Name
  • Ordering Provider Organization Name
  • Ordering Provider Address, Phone AND Fax.

Specimen Collection Information

  • Date and Time of Collection
  • Specimen Type
  • Source

 

To have a customized laboratory requisition please contact your Laboratory Account Manager or call the Laboratory Customer Service Support Team at 616.774.7721 or email LaboratoryServices@spectrumhealth.org.

 

FOR SPECTRUM HEALTH INPATIENT USE, IN DOWNTIME EVENT