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CONSTITUTIONAL (BLOOD) TEST REQUISITION FORM - genetics medicine iu 2025

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The document is a Constitutional (Blood) Test Requisition Form from Cytogenetic Laboratories at Indiana University School of Medicine. It outlines the necessary information for ordering genetic tests, including patient and physician details, clinical information, requested testing types, financial authorization for insurance billing, specimen collection and handling requirements. The form is designed to facilitate the submission and processing of blood samples for various genetic analyses.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Physician(s)' section. Enter the ordering physician's name, address, and contact information. Ensure you provide a signature for authorization.
Next, complete the 'Patient Information' section. Input the patient's full name, address, date of birth, and sex. Indicate if the patient has recently been pregnant.
In the 'Clinical Information' section, specify the collection date and time. Select whether the sample is blood or cord blood and include who collected it.
Proceed to 'Referring Diagnoses' and check all applicable diagnoses that pertain to the patient’s condition.
Fill out the 'Requested Testing' section by selecting appropriate tests based on clinical needs. Ensure you note any specific requirements for specimen collection.
Complete the 'Patient Financial Authorization/Insurance Benefit Verification' section carefully, ensuring all signatures are obtained where necessary.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (34 Votes)
2015	4.3 Satisfied (221 Votes)
2014	4.4 Satisfied (183 Votes)
2013	4 Satisfied (58 Votes)

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