Requisition Form

Requisition Form
2500 E T C Jester Blvd #201 Houston, TX 77008
T: (713) 485-6965
F: (832) 218-1090
E: support@moduslaboratories.com
CLIA ID: 45D2245388
Provider Information
Group Name*
Practice Name
Provider Name*
Patient Information
Patient Name*

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Patient Allergies*
Billing Information
Primary Insurance Name*
Primary Insurance ID*
Primary Insurance Group No*
Is there a secondary insurance?

YesNo
Secondary Insurance Name
Secondary Insurance ID
Secondary Insurance Group No
Upload Documents

Cancelof
Collection Details
Sample 1 Collection Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Anatomical Location*
Is an additional sample being submitted?

YesNo
Sample 2 Collection Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample 2 Notes/Anatomical Location
Sample 3 Collection Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample 3 Notes/Anatomical Location
PCR Order
Show list of test options that includes details about pathogens and antibiotic resistance?

YesNo
Wound

Pathogens: Herpes Simplex Virus 1 (HSV1) • Herpes Simplex Virus 2 (HSV2) • Varicella zoster virus • Endogenous Contro • Streptococcus agalactiae (Group B) • Enterobacter cloacae complex • Escherichia coli • Staphylococcus aureus • Klebsiella oxytoca complex • Klebsiella pneumoniae • Proteus mirabilis • Trichophyton mentagrophytes • Bacteroides fragilis • Pseudomonas aeruginosa • Morganella morganii • Candida albicans • Aspergillus fumigatus • Streptococcus pyogenes • Acinetobacter baumannii • Candida glabrata

Antibiotic Resistance: ermA • ermB • ermC • dfrA1 • dfrA5 • QnrA1&2 • QnrB • QnrS • Sul1 • Sul2 • Sul3 • tetM • tetB • blaTEM • CTX-M-Grp 1 • CTX-M-Grp2 • CTX-M-Grp8/25 • CTX-M-Grp9 • blaSHV • blaKPC • mecA • ACT/MIR • FOX • ACC • Vancomycin A •
Vancomycin B • BIaNDM • BlaIMP • blaVIM
Test Ordered*

WoundOther
*If submitting a specimen for Histopathology, please complete the Histopathology Requisition form.
Diagnostic Code 1*
Diagnostic Code 2
Diagnostic Code 3
Diagnostic Codes Manual Entry
Patient Acknowledgment

(Optional)
This specimen was provided voluntarily for analysis, and I authorize Modus Laboratories to process, bill and provide results.

Clear
Authorized Healthcare Provider Acknowledgment

(Required)
By signing below, I hereby request and authorize the reference/testing lab to utilize this information to perform the testing for the indicated patient. I verify that I am the authorized provider of health care ordering this test as medically necessary to the assessment, diagnosis, or detection of disease, illness, symptom, disorder, or other health-related issue. If the undersigned provider checks off a panel as the provider’s choice, Modus Laboratories understands that the provider has determined that all of the component tests are medically necessary, and will perform, report and bill for all such component tests. I hereby further authorize Modus Laboratories to send, in its judgment, the patient specimen to another reference laboratory for testing on the reference laboratory's similar test panel(s), and all the component tests, as shared with me and as may be updated from time to time.*

Clear
Date*

MonthDayYear
Should be Empty:

Requisition Form

Provider Information

Patient Information

Billing Information

Collection Details

PCR Order

Wound

Patient Acknowledgment

Authorized Healthcare Provider Acknowledgment