The user should pay particular attention to those parts of the requisition noted as required information. Without the minimal required information requested on the University of Iowa Health Care requisitions, processing of the referred specimen may be delayed until the information can be obtained from the referring client.

Contact UIDL Client Services at 319-384-7212 (toll free: 1-866-844-2522) for assistance with selecting or completing any pathology outreach requisitions.

All customer accounts require a unique “Client Number” which identifies the referrer to us. The Client Number should be used on all documents submitted. Contact UIDL Client Services at 319-384-7212 (toll free: 1-866-844-2522) to set up a new account.

For Client Use Only – Optional Information used by referring institution, if desired.

Requisition Date

Completed By

Accn#

Part A Patient Information – Required on all requisitions

Patient Name	Phone
Street	DOB
City	Sex
State	SSN
ZIP

Part B Referring Provider Information - Required on all requisitions

________ - Client #	Phone
Street	Fax
City	Referring Physician
State	Referring Physician UPIN
Zip

Part C Specimen Information – Required information differs by specimen type
Anatomic Pathology Consult Requisition (includes non-PAP cases)

Material Submitted	Clinical Differential Diagnosis
Consultation Requested	Previous Tests Relevant to Current Problem
Pertinent Clinical History/Findings	List Cytology Specimens and Collection Method (non-PAP)

Flow Cytometry Requisition and Immunopathology Requisition

Specimen Collection Date	Pertinent Clinical History and Findings
Specimen Collection Time	Clinical Differential Diagnosis
Tissue Source/Site	Previous Tests Relevant to Current Problem

Cytopathology Requisition

Check PAP Type	Contraception/Hormonal Therapy
Conventional PAP Smear (Diag or Screen)	Date of Gyn Surgery
Age	Previous History of Cancer
LMP	Treatment
Abnormal Bleeding	Clinical Comment
Status

Laboratory Requisition

Specimen Collection Date

Specimen Type (Serum, Whole Blood, Other)

Specimen/Test Requested

Part D Send Bill To:

Attn: Accounts Payable, ______

OR

Patient Insurance – If Patient Insurance is checked this information is required

Primary Insurance Coverage

Secondary Insurance Coverage

Required ICD-9 Codes

Authorization/Referral #

Guarantor Name

Guarantor Address

Specialized Testing Requisitions

DeGowin Blood Center Requisition

Molecular Genetics General Consult Requisition

Molecular Genetics Muscular Dystrophy Consult Requisition

Molecular Oncology & Infectious Disease Requisition

Muscular Dystrophy Requisition

Prenatal FSHD Testing Requisition