ANMC LABORATORY FIELD REQUISITION
Alaska Native Medical Center Laboratory
City/Village FULL NAME (NO ABBREVIATIONS)
4315 Diplomacy Drive
Anchorage, AK 99508
Phone: (907) 729-1200, Fax: (907)729-1227
All Information in yellow/red fields is required. Use full names (NO ABBREVIATIONS).
Field Requisition and Specimen Requirements Into Available at: http://anmc.org/services/laboratory
Diagnosis/Signs/Symptoms in ICD-9 or IDC-10 Format (Highest Specificity)
Patient's Name (Last)
Patient's Name (First)
Clinic's FULL NAME (NO ABBREVIATIONS)
Clinic's Phone #
Clinic's Fax #
Collection Date
Collection Time
Bill To: __ Client/Clinic __ Medicare ( __ Primary
__ Secondary) __ Medicaid __ Other Insurance
Sex
Date of Birth
Patient's Relationship to Insured Person:
__ Self
Provider's Name (Last)
MR #
Provider's Name (First)
__ Spouse
__ Child
__ Other
Insured Person's Full Name (If Not Pt) (Last, First)
Note: Only order those tests which are medically necessary for the diagnosis and treatment of the patient. Medicare does
not pay for tests for which documentation does not support that the tests were reasonable and necessary. Medicare
generally does not cover routine screening tests, even if you consiter the tests appropriate.
Insurance Company Name
Insured's SS #
Subscriber/Member #
Carrier Code
Plan Name or #
Group #
Physician's Provider #
Workers's Comp (Y/N)
Employer's Name
Employer's #
Provider's Signature: ______________________________________________________________________________
COMMON TEST PANELS
Acute Hepatitis Panel (HAV IgM, HBV
Core IgM, HBV Surface Ag, HCV Ab)
Basic Metabolic Panel (Na, K, Cl, Glu,
CO2, BUN, Creat, Ca, GFR)
Chronic Hepatitis Screen (HAV Ab, HBV
Core Ab, HBV Surface Ab, HCV Ab)
Comprehensive Metabolic Panel (Na, K,
Cl, Glu, CO2, BUN, Creat, Ca, TP, Alb, TBili, Alk Phos, ALT,
AST, GFR)
Electrolyte Panel (Na, K, Cl, CO2)
Hepatic Function Panel (Alb, TBili, DBili,
Alk Phos, TP, ALT, AST)
Lipid Panel (Fasting Specimen)
(TChol, Trig, HDL, LDL, Chol:HDL Ratio)
Renal Function Panel (Na, K, Cl, Alb, Ca,
CO2, Creat, Glu, PO4, BUN, GFR)
HEMATOLOGY TESTS
Hemoglobin and Hematocrit
CBC with Differential
CBC without Differential
Manual Differential
Reticulocyte count
Erythrocyte Sedimentation Rate (ESR)
SST
SST
SST
SST
SST
SST
SST
SST
LAV
LAV and
SMEAR
LAV
SMEAR
LAV
LAV
ALPHABETICAL TESTS
ABO Group & Rh
Acetaminophen
AFP
Albumin
Alkaline Phosphatase
ALT
Amylase
Pink or LAV
Antibody Screen w/ Reflex Antibody ID *
Pink or LAV
Antibody Titer
AST
Bilirubin, Direct
Bilirubin, Total
Calcium
Cholesterol, Total
CK, Total
Pink or LAV
SST
SST
SST
SST
SST
SST
SST
SST
SST
SST
SST
SST
Legend: * = Has potential reflexive testing.
Note: In general, all specimens should be sent with a gel
cold-pack. Refer to chart on ANMC webite for specimen
type, stability, and transport requirements:
http://anmc.org/services/laboratory/specimen requirements
Updated 3/31/15
ALPHABETICAL TESTS
Creatinine
Direct Antiglobulin Test (DAT)
Digoxin
Ethanol
Ferritin
Folate
Gentamicin
GGT
Glucose
HCG (Serum), Quant
HCG (Urine), Qual
Hemoglobin A1C
Hep A Antibody, Total IgG/IgM
Hep A Antibody, IgM
Hep B CORE Antibody *
Hep B Core IgM Antibody
Hep B Surface Antibody
Hep B Surface Antigen *
Hep B CARRIER PANEL w/ AFP
Hep C Antibody
Hep C CARRIER PANEL w/ AFP
HIV Screen *
Iron Panel (Iron, TIBC, UIBC, % Sat)
Iron, Total
LDH
Magnesium
Phenobarbital
Phenytoin (Dilantin)
Phosphorous
PT with INR
PTT, Activated
Potassium (K)
PSA
PSA w/ Reflex Free PSA *
PTH, Intact
RPR
Rubella Antibodies, IgG
Salicylate
Sodium
SST
Pink or LAV
SST
SST
SST
SST
SER
SST
SST
SST
URINE
LAV
SST
SST
SST
SST
SST
SST
SST
SST
SST
ALPHABETICAL TESTS
T-3, Free
T-4, Free
T-4, Total
Triglyceride
TSH
TSH w/ Reflex FT4 *
Urinalysis Dipstick Only
Urinalysis w/ Reflex Micro & Culture *
Urinalysis w/ Microscopic Exam
Valproic Acid
Vancomycin
Vitamin B12
Vitamin D 25 OH, Total
MICROBIOLOGY TESTS
SST
SST
SST
SST
SST
SST
BD Tube
BD Tubes
BD Tube
SST
SST
SST
SST
Source of Specimen (REQUIRED):
SST
SST
SST
Aerobic Bacterial Culture (Source: ___________________ )
SST
Anaerobic Bacterial Culture (Source: _________________ )
Swab
SST
Chlamydia/GC (APTIMA) (Source: __________________ )
APTIMA
SER
Clostridium Difficile (DNA Amplification)
Stool
SER
Gram Stain (Source: ___________________ ) Swab
SST
SST
Influenza A & B (Rapid Antigen)
Hep B Quant Viral Load (PCR)
Hep C Quant Viral Load (PCR)
Parasite Antigen Panel
Rotavirus (Rapid Antigen)
RSV (Rapid Antigen)
Sputum, Upper Respiratory Culture
Stool Culture
Throat Culture, Beta Strep Group A
SST
Trichomonas (APTIMA) (Source: ___________________ )
BLUE
BLUE
SST
SST
SST
SST
SST
SST
Prenatal Triple Test/Maternal Serum Evaluation
Gestational Wks: ________ Maternal Weight: ________
Race: _______________ Insulin Dependent: _____
Previous Results/History: ________________________
Swab
NP Swab
SST
SST
Alpha Tec
Stool
NP Swab
Sputum
Alpha Tec
Swab
APTIMA
Urine Culture __ Clean Catch __ Cath BD Tube
ADDITIONAL TESTS / NOTES / 24 Hour Urine Volume