One Time Authorization for Restricted or Off-Formulary Tests

* Indicates required field

Submitting Provider* Primary Contact Name* Primary Contact Email Address* Phone Number* Fax Number* Department/Office Name* Street Address City State Zip Patient Name* Medical Record Number*

If there is no Medical Record Number, specify "N/A".

Sex*

Male Female

Date of Birth (in form MM/DD/YYYY)* Health Insurance (List all, separated by commas) Diagnosis*

Compliance is Mandatory and Regulated. For the laboratory to bill property and receive payment for tests ordered on Medicare Beneficiaries, specific ICD-9 code(s) or a descriptive diagnosis must be included on each patient for each test ordered. It is critical that the diagnosis provided to lab is consistent with those recorded in the patient medical record on the date of service.

Tests Requested (List all, separated by commas)* Explanation*

Please provide patient diagnosis and a detailed explanation as to how results of requested test(s) will influence your clinical management and care of this patient. If the patient is a hospital in-patient, please explain how these results will influence your treatment plan during current admission.

I am the Physician of record or a Consulting Physician caring for the patient identified above. I am requesting a laboratory assay that may not be provided by the URMC Laboratories of Strong Memorial Hospital/Highland Hospital and may require shipment of sample to an outside reference laboratory to perform this assay. I understand that the time required to process, ship, and to receive results from an outside reference laboratory generally requires a minimum of five (5) business days, and that for certain assays, results may not be available for several weeks.

In making this request I certify that the results of the laboratory assay(s) that I have requested above are medically necessitated and are likely to alter my diagnosis and/or my treatment plan for this patient.

I Accept*

Our Privacy Policy

URMC Labs Test Index

A | B | C | D | E | F | G
H | I | J | K | L | M | N
O | P | Q | R | S | T | U
V | W | X | Y | Z

Quick Links

Strong Memorial Hospital Lab Directory

Highland Hospital Lab Directory

Lab Supply & Document Order Form

How Can We Serve You Better?

Permits and Certifications