The CCL requisition form is designed to capture accurate information as required by federal or private health care programs.
  • Complete a separate test requisition form for each patient.
  • Record the following:
    1. Ordering provider’s first and last name and/or NPI
    2. Patient name, date of birth, gender
    3. Patient’s phone number, including area code
    4. Collection date and time
    5. Checkmark Billing between “Client” “Patient” and “Insurance”
    6. Insurance information, as necessary (include patient address, insurance plan/number, and policy holder name).
    7. Narrative diagnosis, sign or symptom, or ICD-9 code for each test ordered
  • Mark box(es) with an X indicating the test(s) requested. Use the empty space to write in test orders for tests not preprinted on the requisition.
  • The ordering provider should sign the requisition in the upper right corner whenever possible.
    1. If the ordering provider not sign the requisition, order documentation from the patient’s medical record MUST be made available when requested by CCL
  • Submit the top white copy with the specimen(s).
  • The pink copy to be retained for your records


When ordering laboratory tests for patients who are enrolled in Medicare or other federally funded insurance programs, reimbursement may be limited to:

  • Only tests that are medically necessary for the diagnosis or treatment of the patient. Federally funded programs may not pay for non-FDA approved tests or tests considered research or investigational use only.
  • Medicare does not pay for many tests when ordered as screening. Screening test coverage is limited to those tests included in Preventive Services at the defined frequencies.
  • If there is reason to believe Medicare will not pay for a test, the patient must be informed via the Advance Beneficiary Notice (ABN) of their financial responsibility if Medicare denies payment.
  • CCL and client customized panels should be ordered only when every component of the customized panel is medically necessary.