Laboratory

Accurate, efficient and cost-effective.
Laboratory

HealthEast Medical Laboratory Requisition Form

Thank you for choosing HealthEast Medical Laboratory.

If you are submitting this form fewer than 12 hours before collection time, please call our customer service at 651-232-3500.

If you are seeking Medicare reimbursement, order only tests that are medically necessary.

*Required fields

Seek assistance from staff when drawing?
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Facility information

Collection center number*
Enter your Collection Center number.

Facility Name*
Enter the facility name.

Completed by*
Enter the name of the person completing this form.

Subject
Enter the subject of your message.

E-mail*
Enter a valid e-mail address.

Phone number*
Enter your phone number.

Patient information

First name*
Enter the patient's first name.

Middle initial
Invalid Input

Last name*
Enter the patient's last name.

Date of Birth*
Enter the patient's date of birth.

xx/xx/xxxx

Sex*
Designate the patient's sex.

Is patient's address different than facility's address?*
Indicate if the addresses are different.

Address *
Enter patient's street address.

City *
Enter patient's city.

State *
Select patient's state.

Zip code *
Enter patient's zip code.



Medicare number
Enter the patient's Medicare number.

Room number*
Enter the patient's room number.

Unit name
Enter the unit name.

Chart number
Enter the patient's chart number.

Physician name*
Enter the physician's name.

Last, First

Order information

Type of order*

Select the type of order.

Date of draw*
Enter the date of draw.

xx/xx/xxxx

Please select the desired lab procedures below.
Chemistry

Invalid Input

Hematology

Invalid Input

Miscellaneous

Enter a description for 'Other'.

Please indicate the diagnosis code(s) for each lab procedure selected above. Your request will not be honored without a diagnosis code indicated for each test.*
Indicate the diagnoses for each lab procedure.


A confirmation e-mail will be sent after you submit your request. If you do not receive a confirmation e-mail, please contact Customer Service at 651-232-3500, option 5.