In the event of an EMR downtime, please use the following forms.   A hard copy manual requisition submission must include:

• The patient’s last name, first name, medical record number (MRN)
• Patient location
• Ordering physician, ordering physician code, including secondary provider
• Diagnostic code(s) for requested tests
• Suffix code (outpatient) (SUFFIX will be MRN + DOS)
• Specimen collection date and time
• Individual tests meeting medical necessity or HCFA approved panels, or tests where physician have acknowledged medical necessity requirements and reimbursement limits
• A paper requisition must accompany every surgical pathology and cytopathology specimen

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