Form - HML Add-On Test Request


Accurate, efficient and cost-effective.

Add-On Test Request Form

Thank you for choosing HealthEast Medical Laboratory. Please use the form below to add tests to an existing test order.

*Indicates required field.

Patient first name*
Enter the patient's first name.

Patient last name*
Enter the patient's last name.

Patient birth date*
Enter the patient's date of birth.


Requesting facility*
Enter the facility that is requesting this change.

Name of requesting clinician*
Enter the name of the requesting clinician or physician.

Specimen date*
Enter the specimen date


Specimen time*
Enter the specimen time.

Requester's first name*
Enter your first name.

Requester's last name*
Enter your last name.

Requester's phone number*
Enter your phone number.


Requester's e-mail*
Enter a valid e-mail address.

Original test(s) requested on this specimen
(List each on a separate line) *
Enter the tests that were previously order on this sample.

List test(s) to add
(List each on a separate line)*
Enter the tests that need to be added.

Symptom/diagnosis code for each test*
Enter the symptom or diagnosis code.

For Medicare/Medicaid reimbursement: Only tests or Medicare-approved panels that are medically necessary for patient diagnosis or treatment will be reimbursed. Screening tests will not be reimbursed and should not be submitted for payment.

The OIG states that a physician who orders medically unnecessary tests for which Medicare or Medicaid reimbursement is claimed may be subject to civil penalties under the False Claims Act.

LabWorks clients: Please remember to follow up with an electronic order for this add-on test.

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.

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