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Pathology and Lab Services

Test Requisitions and Consents


Test Requisition & Consent Description
1 Blood Bank Blood Bank Requisition - Outpatient
2 AMC Bone Marrow Req AMC Bone Marrow Requisition
3 Bone Marrow Req (Integrated Oncology) Bone Marrow Requisition (Integrated Oncology)
4 Inpatient Cytogenetics Requisition Inpatient Cytogenetics Requisition
5 Attestation for Chromosome Studies Attestation for Chromosome Studies (Lab Corp)
6 Attestation for Miscellaneous Genetic Testing Attestation for Miscellaneous Genetic Testing
7 Attestation for Cystic Fibrosis Testing Attestation for Cystic Fibrosis Testing
8 Flow Cytometry Request Form Requisition for Flow Cytometry
9 Molecular Diagnostic Requisition Requisition for Molecular Diagnostics/ICD9
10 Factor 5 Leiden Mutation Genetic Consent Factor 5 Leiden Mutation Genetic Consent
11 Prothrombin G20210A Mutation Genetic Testing Consent Form Prothrombin G20210A Mutation Genetic Testing Consent
12 Reproductive Studies Test Requisition Reproductive Studies Test Requisition
13 Transplant Immunology - HLA Test Requisition Transplant Immunology - HLA Test Requisition
14 Allergen Specific IqE Requisition Requisition for RAST Allergy Testing
15 HIV Rapid Test Requisition for OB/Newborns and Occupational Exposures Only Requisition for Rapid HIV OB/Newborns/Occupational Exposures
16 HIV Test Requisition HIV Requisition
17 Offer of and Informed Consent for HIV Testing Offer of and Informed Consent to Perform HIV Testing
18 Informed Consent to Perform an Expedited HIV Test in the Delivery Setting (NYSDOH) Consent to Perform Rapid HIV Testing in the Delivery Setting (NYSDOH)
19 HIPAA Complaint Authorization for Release of Medical Information and Confidential HIV Related Information (NYSDOH) HIPAA Compliant Authorization for Release of Confidential HIV Related Information (NYSDOH)
20 Cytology and Pathology Requisition for Cytology and Pathology testing
21 Dermatopathology and Immunodermatology Requisition Requisition for Dermatopathology and Immunoermatology
22 Advanced Beneficiary Notice (ABN) Standard ABN Form
23 Attestation for Quantitative Hemoglobin Electrophoresis Testing Hemoglobin Fractionation Consent
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