Requisition Form
HNL Genomics (CTGT) offers two ways for you to complete the Test Requisition Form.
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You may complete the requisition form on your PC, then print, sign and enclose the form with your order.
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You may print the blank requisition form, then complete it manually and enclose the form with your order.
Detailed Instructions for Completing the Form
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
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Patient Name, Medical Record Number (MRN) and Date of Birth are required in all cases.
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For insurance cases, Mailing Address, Phone number, Name of Legal Guardian (minors only), and Copy of insurance card (front and back) are all required (see Shipping for detailed instructions).
Additional Reports
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Additional reports are optional. If desired, please provide the name and fax number of the contact person to whom an additional copy of the report should be sent.
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Please 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 Self Pay, or Patient Insurance. If you select Patient Insurance, you must also complete the Patient Self Pay section.
- Please enter all requested information to ensure that your order is processed promptly.
- Please review the Billing and Payment page for additional information.
Test Selection
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Please select all tests requested.
Special Test Instructions
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Indicate step-wise testing order or any other special instructions in this area, if applicable. If no instructions are entered, then all selected tests will be performed concurrently.
Other Information
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Known Familial Mutation – Please provide the nucleotide and amino acid change of the variant and the relationship of the proband to the current patient.
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If the variant was identified at HNL Genomics (CTGT) , please include the HNL Genomics (CTGT) ID or the name and date of birth of the patient in whom the variant was previously identified.
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If the variant was identified by another laboratory, please submit the report issued by that laboratory, if available.
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For prenatal tests, please:
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Check the “Yes” box next to “Is this a prenatal test?” and provide the anticipated delivery date.
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Indicate whether a maternal cell contamination study is requested. (A maternal cell contamination study is highly recommended for all prenatal tests. Please note that there is an additional charge of $370 for maternal cell contamination studies.)
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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”).
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Clinical Information
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For many disorders, knowledge of the patient’s clinical findings is critical for achieving the proper diagnosis. Please provide as much relevant clinical information as possible.
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For insurance purposes, clinical information is typically required.
