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Women’s Health
Requisition Guide
We stand by our results because
we know you depend on them.
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Section A: Clinic Information
Options
Enter Clinic Name & Address OR
Enter Clinic Account Number (provided in Enrollment Confirmation Letter)
Affix custom Clinic Requisition Label (request via website at
Specimens cannot be processed without Clinic Information
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Section B: Sample Information
Print Provider Name
Date specimen collected
Collector Initials
Indicate Specimen Type as Vaginal Swab
Specimens cannot be processed without Requesting Provider
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4. Section C: Patient Information
Patient First & Last Name
Patient DOB
Patient Address (may provide from EMR printout)
Current Medications (may provide from EMR printout)
ICD-10 Codes (must reflect Medical Necessity)
Insurance Information
Req captures Primary Payor
May provide from EMR printout
Send copy of all payor cards
Send copy of DL
Must indicate Primary/Secondary Status
Missing Information will result in reporting and billing delays
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5. Section D: Patient Clinical History
Diagnostic Factors
Last Cycle
Pregnancy status
Recurrent BV concerns
Recurrent Trichomonas concerns
Recurrent Candidiasis concerns
Data required for improved diagnostic accuracy
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6. Section E: Pathogen Testing
Options
May order Comprehensive Panel. Includes all pathogens within Pathogen Panels and Group B Strep
May order individual or combination of Pathogen Panels
May add Pathogen Specific Tests
Rules for Medical Necessity must be followed when ordering Panel(s)
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7. Section F: Authorization
Patient Signature – Required for billing purposes
Provider Signature – Required for billing purpose
Specimens will not be processed without a Provider Signature
Requisitions missing signatures will be faxed to the clinic to request a signature. Specimens will be processed once the requisition is faxed back with a valid signature.
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Lastly: Requisition Labels
Used to connect specimen to paperwork for integrity purposes
Affix label from requisition to collection device
Label device with at least 1 additional unique identifier
Do not label device lids
Acceptable Unique Identifiers
Patient Full First & Last Name
Patient DOB
Requisition label
Specimens lacking 2 unique identifiers will be marked as such. Integrity of the specimen source cannot be confirmed.
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