GYN CYTOLOGY (PAP) REQUISITION FORM
Pap smears must be submitted with this form. All specimens must be properly identified.
- Label slide (Conventional Pap) or SurePath specimen container
- Conventional Pap
- Write patient name on bottom 2/3 of frosted end of slide, using pencil
- Last name, first name or initial
- SurePath liquid-based thin layer Pap
- Write patient name, physician name, and date on specimen container
- Conventional Pap
- Requisition form must be properly and fully filled out:
- Patient name (last, first, middle initial)
- If last name has recently changed, please include former name
- Patient social security number
- Physician name
- Patient date of birth (month, date, year)
- Clinic/hospital patient ID number (optional)
- Patient insurance information (not necessary if billed to clinic/hospital)
- Diagnosis (IDC-10 codes are requested)
- Test requested
- Specimen collection date
- Source of specimen
- Patient history (will print out on results report)
- LMP and hx. of abnormal pap, tx., and surgery are required by CLIA
- Patient name (last, first, middle initial)
- Medicare patients (Advance Beneficiary Notice) a) If you do not have an accurate history of whether the patient has had a pap smear in the last three years, please have the patient sign the Advance Beneficiary Notice that is located in the middle section of the requisition form.
- Your clinic/hospital keeps the yellow (back) copy of requisition form, and sends the white (top) copy to the lab, in a bio-hazard bag with the specimen. More than one pap smear specimen may be placed in a bio-hazard bag. Please make sure that each specimen is properly labeled and accompanied by a properly filled out GYN Cytology requisition form.
NOTE: CLIA regulations dictate that the following information must be recorded on the test request form:
- Patient name
- Patient date of birth
- Patient last menstrual period (LMP)
- Patient history of abnormal pap, treatment., and surgery