Completing-the-Requisition Completing-the-Requisition
Completing the Requisition Completing the Requisition

Completing the Requisition

A requisition form is included with every test kit. See below for tips on completing the form to ensure that your test is processed efficiently. In addition, all Medicare-eligible patients must read and sign the ABN on the back of the requisition, regardless of billing method selected. Tests can be significantly delayed or canceled due to missing or incomplete information.

If you have any questions, please contact us.



Please click on the thumbnail images below to view their placement on the form.

Requisition Form

Step 1

Place a check in one of the boxes to choose the method of payment for this test. For more details on the options available, visit our Billing Options and Overview page.

Bill to box on the Doctor's Data requisition form to select the method of payment.

Step 2.

The physician should read and sign the requisition form and verify that the preprinted address and contact information is correct. Please make any needed changes on the form.

Physician information box on the Doctors Data requisition form to verify and sign.

Step 3.

Check the box to order the complete profile, when appropriate, or circle individual test components to order separately. Write in any other requested information such as the date of the last sample, patient height and weight, etc. For insurance or Medicare patients, clearly circle and provide diagnosis codes for each component ordered.

Tests ordered section of the Doctor's Data requisition form to select test or enter information.

Step 4.

Have the patient completely fill out and sign section four. If the patient or responsible party has not signed the form, the test will be placed on hold until a signature can be obtained. All Medicare-eligible patients must read and sign the ABN on the back of the requisition form.

The patient information section of the Doctor?s Data requisition form with signature required.

Step 5.

If payment for testing is enclosed, the physician or patient must provide check or credit card information. If complete payment information is not provided, the test will be placed on hold.

Payment section of the Doctor's Data Requisition form.

Step 6.

If the patient has opted to have Doctor's Data to file a claim with their insurance or Medicare, this section must be completed in full. Any missing information will result in the test being placed on hold.

Insurance information section is shown here of the Doctor?s Data requisition form.

Advance Beneficiary Notice (ABN)

Step 7.

Write the patient's name and Medicare ID number (Health Insurance Claim Number) at the top.

Picture of the patient name and ID number in the ABN Medicare section of the DDI req form.

Step 8.

Explain to the patient that Medicare will probably not pay for the lab tests being ordered for the reasons indicated, and that if the patient decides to proceed with the laboratory tests, they will be responsible for payment. The estimated cost is indicated for each test.

Picture of an explanation of why Medicare might not pay for tests from DDI ABN form.

Step 9.

If the patient chooses to receive the tests and accept financial responsibility, but wants Doctor's Data to bill Medicare, choose option 1.

Option 1 of the ABN regarding direct bill to Medicare but patient accepts financial responsibility.

Step 10.

If the patient does not want Medicare to be billed, so they can take advantage of any available prepayment discounts or for other reasons, choose option 2.

Option 2 of the ABN form where the patients does not want DDI to bill Medicare.

Step 11.

If the patient does not want to receive the tests and accept financial responsibility for them, they can check option 3. You will also want them to sign and date the form for your records. In this case, do not send specimens to the laboratory.

Option 3 of the ABN form where the patient does not want the tests or be responsible for payment.

Step 12.

All ABNs must be dated and signed by the patient before a test will be performed.

Thumbnail of the signature and date line of the ABN for Doctor?s Data.

Thumbnail photo of the DDI test requisition form front page.