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
Note: This is Modus’s general requisition form. If you would like to request a customized version tailored to your practice’s workflow, please click here to submit a request.
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
Patient Allergies
Billing Information
Is this patient residing in a skilled nursing facility, long-term care, or inpatient rehabilitation facility?
Facility Name
Primary Insurance Name
Primary Insurance ID
Primary Insurance Group No
Is there a secondary insurance?
Secondary Insurance Name
Secondary Insurance ID
Secondary Insurance Group No
Upload Documents

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Collection Details
*If submitting a specimen for Histopathology, please complete the Histopathology Requisition form.
Sample 1 - Collection Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample 1 - Anatomical Location
Sample 1 - Test Ordered

Other
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
Sample 1 - Diagnostic Code 1
Sample 1 - Diagnostic Code 2
Sample 1 - Diagnostic Code 3
Sample 1 - Diagnostic Codes Manual Entry
Is an additional sample being submitted?
Sample 2 - Collection Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample 2 - Notes/Anatomical Location
Sample 2 - Test Ordered

Other
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
Sample 2 - Diagnostic Code 1
Sample 2 - Diagnostic Code 2
Sample 2 - Diagnostic Code 3
Sample 2 - 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.
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.
Date

MonthDayYear
Should be Empty:

Requisition Form

Provider Information

Patient Information

Billing Information

Collection Details

Wound

Wound

Patient Acknowledgment

Authorized Healthcare Provider Acknowledgment