Secure Lab Requisition Submission

Submit a valid laboratory requisition and the information needed for Bluegrass Specimen Collection to review, coordinate, and schedule mobile specimen collection services.

Submission does not confirm acceptance of the case or an appointment.

Requestor & Provider Information

Organization / Practice Name

Requestor First Name

Requestor Last Name

Role / Title

Business Email

Direct Phone Number

Ordering Provider Name

Fax Number

Patient & Collection Location

Patient Legal First Name

Patient Legal Last Name

Date of Birth

Month

Day

Year

Patient Phone Number

Complete Collection Address

Collection Location Type

Patient Home

Physician Office

Assisted Living / Long-Term Care Facility

Other

Preferred Collection Date

Month

Day

Year

Preferred Time Window

Morning

Afternoon

No Preference

Tests & Laboratory Destination.

Tests / Panels Requested

Summary only. The attached laboratory requisition remains the controlling document.

Destination Laboratory Network / Health System

Specific Laboratory Location / Drop-Off Site

Enter the specific facility or location, if known. Example: IU Health Bedford Hospital Laboratory.

Drop-Off Address, if Known

Include the street address, city, state, and ZIP code if available.

Has the Destination Laboratory Been Confirmed?

Yes — Location Confirmed

No — Confirmation Needed

Not Yet Determined

Unknown

Fasting Requirement

No Fasting Required

Fasting Required — 8 Hours

Fasting Required — 10 Hours

Fasting Required — 12 Hours

Fasting Required — Other Duration

Fasting Required — Duration Unknown

Not Stated on Requisition — Confirmation Required

Has the Patient Been Given the Required Preparation Instructions?

Yes

Unknown

Not Applicable — No Special Preparation Required

Source of Fasting / Preparation Instructions

Patient Collection Considerations

Known Difficult Draw / Hard Stick?

Yes

Unknown

Additional Collection Considerations

Please include only information directly relevant to safely and successfully completing the specimen collection.

Specimen Handling Requirements

Special Handling Instructions

*Enter any specimen processing, temperature, timing, transport, or laboratory-specific instructions provided by the ordering provider, destination laboratory, or research protocol. Do not substitute typed instructions for the official laboratory requisition, laboratory instructions, or study protocol.

Service Fee Responsibility

Who Is Responsible for the Mobile Collection Fee?

Billing Contact Information

If someone other than the requestor is responsible for payment, provide the billing contact name, organization, phone number, and email address.

Purchase Order / Authorization / Reference Number

Enter any purchase order, authorization, study, case, or internal reference number associated with this request.

Requisition & Supporting Documents

Upload Complete Laboratory Requisition

PDF, JPG, JPEG, PNG.

Upload all pages of the valid laboratory order or requisition. The document should clearly identify the patient, ordering provider, requested testing, and laboratory processing information.

Does the Requisition Include All Pages?

Yes

Unknown

Additional Supporting Documents

Upload only documents directly relevant to the requested specimen collection, such as laboratory handling instructions, research protocols, collection kit instructions, or courier documentation.

Documents Included With This Submission

Laboratory Requisition / Order

Special Handling Instructions

Research Study Protocol or Collection Instructions

Collection Kit Instructions

Courier / Transport Instructions

Authorization & Acknowledgment

Authorization to Submit Patient Information

I attest that I am authorized to submit this information and the attached documentation to Bluegrass Specimen Collection for the purpose of reviewing, coordinating, and performing the requested specimen collection services.

Requisition Acknowledgment

I understand that the attached laboratory requisition or order remains the controlling clinical document and that information entered in this form does not replace or modify the official order.

Scheduling and Acceptance Acknowledgment

I understand that submitting this form does not confirm acceptance of the case, create an appointment, or guarantee service availability. Bluegrass Specimen Collection will review the requisition, collection requirements, service location, laboratory destination, and specimen handling needs before confirming service.

Accuracy of Information

I confirm that the information provided in this submission is accurate to the best of my knowledge and that any known special collection, preparation, processing, or transport requirements have been disclosed.

Authorized Submitter Full Name

Enter the full name of the person completing this submission.

Please review all information and uploaded documents before submitting. Bluegrass Specimen Collection may contact the requestor for clarification before service can be confirmed.

Your submission will be reviewed before any service is scheduled or confirmed.