Requisition Forms

For convenience, CTGT offers two ways for you to complete an order form.

1.  You may complete the requisition form on your PC screen, and then simply print, sign and enclose the form with your order.  To do this, please click on this form:

   Test Requisition Form - complete electronically and print

2. You may print the blank requisition form, complete it manually, and then enclose the form with your order.  To do this, please click on this form:

   Test Requisition Form - print and complete
 

Detailed Instructions For Completing Forms:

If this is your first time completing our forms, please be sure to review the detailed instructions below.  If you are completing the form manually, please use a ball point pen and PRINT all information CLEARLY.

Patient Information

• Patient Name, Medical Record Number (MRN) and Date of Birth are required in all cases.
• For insurance cases, Mailing Address, Phone number and Name of Legal Guardian (minors only) are all required.

Referral Source

• Be sure to provide all contact information, especially the name and the fax number of the referring physician and / or genetic counselor.
• Physician’s signature is required.

Additional Reports

• Additional reports are optional.  If desired, please be sure to provide all contact information, especially the name and the fax number of the contact person.
• Please be sure to include any unique identifiers that are required to be on reports (MRN, ACCN, Sample number, Account number, etc.) in the Referring Lab ID# box.

Payment Information

• You may select Institutional Billing, Patient Insurance or Patient Direct Pay.  If you select Patient Insurance, you must also complete the Patient Direct Pay section.
• Please be sure to enter all requested information to ensure that your order is processed promptly.
• Please review the Billing and Payment page for additional information.

Test Selection

• Please indicate all desired tests on the list.
• Use the Special Test Instructions area below to indicate step-wise testing order or other special instructions if applicable.  If no instructions are entered, then all indicated tests will be performed.

Other Information

• For prenatal tests, please:
  • Check “Yes” and provide the anticipated delivery date.
  • Indicate whether a maternal cell contamination study is requested. (Recommended for all prenatal tests.  Please note that there is an additional charge of $285.00 for maternal cell contamination studies.)
  • If a maternal blood sample is submitted prior to the fetal sample, please use this area to indicate what the blood is to be used for (for example:  “Maternal blood sample for MCC, cultured fetal cells to follow”).
• Known Familial Mutation – At a minimum, please provide mutation information, name and CTGT ID for proband, and relationship of the proband to the current patient. For familial mutations not identified by CTGT, please send a copy of the proband’s report if available.

Clinical Information

• For many disorders, it is critical to know the clinical findings in order to achieve the proper diagnosis.  Please provide as much relevant clinical information as possible.