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EXAS COVID-19 Test Requisition Form - WI - Test Menu

EXAS COVID-19 Test Requisition Form - WI - Test Menu 2025

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The document is a COVID-19 Test Requisition Form for SSM Health in Wisconsin, detailing the necessary provider and patient information required to order a COVID-19 test. It includes sections for diagnostic codes, specimen type, patient demographics, and certification by the ordering provider, ensuring compliance with HIPAA regulations.

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Click ‘Get Form’ to open the EXAS COVID-19 Test Requisition Form in our editor.
Begin by filling out the 'Provider & Order Information' section. Enter the healthcare organization name, provider name, and NPI number. Ensure you include the appropriate diagnostic codes that reflect the reason for testing.
In the 'Specimen Type' section, select the method of specimen collection such as Nasopharyngeal Swab or Throat Swab. Fill in the collection date and time accurately.
Proceed to 'Patient Demographics'. Complete all required fields including Patient ID/MRN, DOB, first and last name, and contact numbers. Make sure to indicate the patient's ethnicity and race as applicable.
Finally, ensure that you sign and date the certification statement confirming your authority to order this test before submitting.

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