Multiple Patient/Sample - Same Test - Requisition



COVID-19 MULTIPLE/SAMPLE REQUISITIONMichigan Department of Health and Human ServicesBureau of Laboratories3350 North Martin Luther King Jr. Blvd.Lansing, Michigan 48909Phone: 517-335-8059 Laboratory RecordsFax: 517-335-9871517-335-8067 Technical Information mdhhslabDate received at MDHHSEnter STARLIMS Code if known FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????Return results to:Phone FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ????? FORMTEXT ?????Fax FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????Physician:National Provider Identifier FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????PATIENT/SAMPLE INFORMATIONMDHHS Specimen #Date CollectedSpecimen SourcePatient Name (Last, First)Date of BirthSex1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FPatient CityPatient Zip CodeRaceEthnicity FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX AI/NA FORMCHECKBOX AS FORMCHECKBOX BK FORMCHECKBOX NH FORMCHECKBOX WH FORMCHECKBOX OTH FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic FORMCHECKBOX OTHMDHHS Specimen #Date CollectedSpecimen SourcePatient Name (Last, First)Date of BirthSex2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FPatient CityPatient Zip CodeRaceEthnicity FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX AI/NA FORMCHECKBOX AS FORMCHECKBOX BK FORMCHECKBOX NH FORMCHECKBOX WH FORMCHECKBOX OTH FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic FORMCHECKBOX OTHMDHHS Specimen #Date CollectedSpecimen SourcePatient Name (Last, First)Date of BirthSex3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FPatient CityPatient Zip CodeRaceEthnicity FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX AI/NA FORMCHECKBOX AS FORMCHECKBOX BK FORMCHECKBOX NH FORMCHECKBOX WH FORMCHECKBOX OTH FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic FORMCHECKBOX OTHMDHHS Specimen #Date CollectedSpecimen SourcePatient Name (Last, First)Date of BirthSex4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FPatient CityPatient Zip CodeRaceEthnicity FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX AI/NA FORMCHECKBOX AS FORMCHECKBOX BK FORMCHECKBOX NH FORMCHECKBOX WH FORMCHECKBOX OTH FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic FORMCHECKBOX OTHMDHHS Specimen #Date CollectedSpecimen SourcePatient Name (Last, First)Date of BirthSex5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FPatient CityPatient Zip CodeRaceEthnicity FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX AI/NA FORMCHECKBOX AS FORMCHECKBOX BK FORMCHECKBOX NH FORMCHECKBOX WH FORMCHECKBOX OTH FORMCHECKBOX Hispanic FORMCHECKBOX Non-Hispanic FORMCHECKBOX OTHIndicate Test Reason Below FORMCHECKBOX Diagnosis FORMCHECKBOX SurveillanceDEFINITIONS/EXPLANATIONSRETURN RESULTS TO: Name and address of your institution (hospital, clinic, health department, state agency, etc.). Please include phone number and fax number.PHYSICIAN: Name of the physician or party authorized to order testingNATIONAL PROVIDER IDENTIFIER (NPI): The NPI is a unique identification number for covered health care providers, must match with the name of the ordering party.MDHHS SPECIMEN NUMBER: For MDHHS Laboratory Use OnlyDATE COLLECTED: The date (MM/DD/YYYY) that the specimen was collected from the patient.SPECIMEN SOURCE: Type of collection performed (Nasopharyngeal, Nasal, Throat, etc.)PATIENT NAME: Patient’s name (first and last). Must match specimen label exactly.DATE OF BIRTH: Patient’s date of birth (MM/DD/YYYY). Must match the specimen label exactly.SEX: The gender the patient identifies with.RACE:AI/NA = American Indian or Native AlaskanAS = AsianBK = Black or African American NH = Native Hawaiian or Pacific IslanderWH = White or CaucasianOTH = Other RaceThe Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. ................
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