Forms
- Additional / Add-On Test Request
- Blood Bank Specimen Form
- Test Cancellation
- Corrected Report – Gen Lab
- Corrected Report – Pathology
- Fax Discontinuation Form
- Corewell Health West Supply Order Form (X24639)
- Corewell Health West NEW Lab Client Request
- Office Moving or Discontinuing Services Update
- Provider Updates
- Supply Order Form (X06246)
- New Lab Client Request Inquiry
- New Lab Client Request For Build
- ABN (Advanced Beneficiary Notice) (X13553)
- Coding Quality Information
- Coding, Correction, Adjustment, Credit for patient billing (2/22)
- HIV Consent Form
Genetic testing
- Informed Consent for Genetic Testing – English (X17150, 1/15)
- Informed Consent for Genetic Testing – Spanish (X19216, 7/16)
- Informed Consent for Genetic Testing – Patient Education Book – English (8/15) – Provided by the Michigan Department of Health & Human Services
**IMPORTANT NOTE: The following information is required on all laboratory requisitions, failure to provide this information may result in delay of results or possible specimen cancellation and request for recollection
Patient Information
- Full name (legal name) including middle initial
- Birth Date
- Address and Phone Number
Billing Information
- Policy holder name
- Policy holder address
- Insurance name, address, and type
- Contract, Plan or Group Numbers
- Policy holder’s employer
- Relationship to patient
- Note: A copy of patient’s insurance card (front and back) is advised.
Provider Information
- Ordering and Attending Provider Name
- Ordering Provider Organization Name
- Ordering Provider Address, Phone AND Fax.
Specimen Collection Information
- Date and Time of Collection
- Specimen Type
- Source
To have a customized laboratory requisition please contact your Laboratory Account Manager or call the Laboratory Customer Service Support Team at 616.774.7721 or email LaboratoryServices@spectrumhealth.org.
FOR SPECTRUM HEALTH INPATIENT USE, IN DOWNTIME EVENT