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The document is a Test Requisition Form from Penn Medicine, detailing the necessary information and requirements for submitting patient specimens for genetic testing. It includes sections for patient and physician information, sample details, billing information, and specific specimen requirements for various types of tests. The form emphasizes the importance of including pathology reports and adhering to transport conditions to ensure specimen integrity.

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Click ‘Get Form’ to open the TEST REQUISITION FORM in the editor.
Begin by filling out the PATIENT INFORMATION section. Enter the patient's first name, last name, date of birth, and medical record number in the required fields marked with an asterisk (*).
Next, move to SAMPLE INFORMATION. Select the patient’s gender and indicate whether they are an outpatient or inpatient.
In the PHYSICIAN INFORMATION section, provide details such as diagnosis, date of collection, specimen site, and contact information for the physician.
Complete the BILLING INFORMATION by selecting insurance type and entering relevant details like insured name and relationship to patient.
Finally, review all entries for accuracy before signing and dating at the bottom of the form. Ensure all required fields are filled out.

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