Downloads
Billing Services Forms
ABN (Advanced Beneficiary Notification Form)
The Hyperlinks below will provide a easy to view and printable ABN form. Once open click the Printer Icon in the pdf program within the open form.
Printable ABN form (English)
Printable ABN form (Spanish)
View ABN Instructions
ABN Information Booklet
This is informative document, provided from the Department Of Health And Human Services / Centers for Medicare and Medicaid Services, explains all about the use of the Advance Beneficiary Notice (ABN).
Allergy Panels and Billing Information
The Hyperlinks below will provide a printer friendly allergy panels. Once open click the Printer Icon in the pdf program within the open form.
General Allergy Panels
Allergist Specific Panels
Allergy memo 07-14-14
Allergy memo 08-01-14
Allergy Testing Prior Authorization Overview
Allergy Panels with CPT codes for Tests
Allergy tests that do not require a 90 modifier
Allergy pre-authorization form how-to information sheets
Commonly Used ICD10 codes for testing
These are the most commonly used dx codes for the test or specialties listed below. Please refer to the payer policies for a complete list of payer approved diagnosis codes.
Allergy testing
Chemistry testing
Coagulation testing
COVID-19 testing
Drug testing
Gastrointestinal testing
Microbiology testing
OBGYN testing
Oncology testing
Rheumatology testing
Urology testing
Vitamin D testing
Vitamins, Additional testing
Molecular Pre-Authorization Requisition Form
Many insurances are requiring pre-authorizations for genetic and molecular testing. If noted above the patient’s insurance company is requiring the ordering physician to obtain a pre- authorization before additional testing can be performed. The Hyperlink below will provide a printer friendly alert values pages. Once open click the Printer Icon in the pdf program within the open form.
Molecular Pre-Authorization Requisition Form
Molecular testing waiver
Molecular and Biomarker Information
Click here for more information about pre-authorization.
Patient Agreement Form
Patient agreements forms used by our clients who collect patient specimens within their offices to inform patients of their rights and responsibilities.
Patient Agreement form
Patient Agreement form (Spanish)
Provider Billing Option Forms
The Hyperlinks below will provide a easy to view and printable version of helpful billing forms. Once open click the Printer Icon in the pdf program within the open form.
Physician Request to Bill Patient
Physician Request to Bill Physician
Physician Request to Change Diagnosis
Alert Values
The Hyperlinks below will provide a printer friendly alert values pages. Once open click the Printer Icon in the pdf program within the open form.
Alert Values
Anatomic Pathology Specimen Quick Reference
The Hyperlink below will provide a printer friendly Anatomic Pathology Specimen Quick Reference Sheet. Once open click the Printer Icon in the pdf program within the open form.
Anatomic Pathology Specimen Quick Reference Sheet
Optimal tissue handling for specimens that will potentially be utilized for assessment of breast cancer prognostic markers.
Optimal tissue handling for ER PR HER2 Breast Cancer prognostic markers
Antibiograms
Our hospital antibiogram data measures the regional biological resistance to antibiotics of substances causing disease and allows prior knowledge of the effectiveness of drug therapy so as to make it more efficient. *(Revised)
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St John Medical Center |
Jane Phillips EMMC |
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St John Owasso Medical Center |
St John Sapulpa Medical Center |
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St John Broken Arrow Medical Center |
Jane Phillips Nowata |
Body Fluid Analysis
The Hyperlink below will provide a easy to view and printable version of body fluid analysis information. Once open click the Printer Icon in the pdf program within the open form.
Body Fluid Analysis
CLIA and CAP Certificates
The Hyperlinks below will provide a easy to view and printable CLIA and CAP certificates for Regional Medical Laboratory (RML) and Pathology Laboratory Associates (PLA). Once open click the Printer Icon in the pdf program within the open certificate.
Click here to view CLIA and CAP certificates.
Coagulation Forms
Patient Questionnaire
The Hyperlink below will provide a easy to view and printable Coagulopathy Questionnaire. Once open click the Printer Icon in the pdf program within the open form.
Coagulopathy Questionnaire Form Updated
Specimen Processing - Double Spin Procedure
The Hyperlink below will provide a easy to view and printable Coagulation Double Spin Procedure. Once open click the Printer Icon in the pdf program within the open form.
Coagulation Double Spin Procedure
Cystic Fibrosis Forms
The Hyperlinks below will provide a easy to view, and printable Cystic Fibrosis Patient Information Sheet and Consent form. Once open click the Printer Icon in the pdf program within the open form.
CF Consent form
CF Patient Information form
Hematopathology (Bone Marrow and Flow Cytometry Work-up) Requisition
The Hyperlink below will provide a easy to view and printable Oncology Work-up Requisition. Once open click the Printer Icon on the left side in the toolbar.
Hematopathology Work-up Requisition
In addition to filling out the Hematopathology Work-Up Requisition, please use the Bone Marrow collection form as a checklist to document the specimens collected and submitted to the laboratory. Please fill out this form and submit it alongside your specimens. Once open click the Printer Icon on the left side in the toolbar.
RML Bone Marrow Collection Form
The Hyperlink below will provide a easy to view and printable Bone Marrow Collection Quick Reference Guide. Once open click the Printer Icon on the left side in the toolbar.
Bone Marrow Collection Quick Reference Visual Guide
Cytogenetics is the study of chromosomes and the related disease states caused by numerical and structural chromosome abnormalities. A several cell or tissue types can be useful to obtain chromosome preparations required in the assay. These samples include peripheral blood, bone marrow, amniotic fluid, and products of conception. Although specific techniques differ according to the type of specimen used, the basic method for obtaining a chromosome preparation is similar.
Fluorescent IN SITU Hybridization (FISH) is a relatively new technology utilizing fluorescently labeled DNA probes to detect or confirm gene or chromosome abnormalities that are generally beyond the resolution of routine Cytogenetics. The sample DNA is first denatured, a process that separates the complimentary strands within the DNA double helix structure. The fluorescently labeled probe of interest is then added to the denatured sample mixture and hybridizes with the sample DNA at the target site as it reforms itself back into a double helix. The probe signal can then be seen through a fluorescent microscope and the sample DNA scored for the presence or absence of the signal.
INVITAE (CombiMatrix) Requisition Form
The Hyperlink below will provide a easy to view and printable RML CombiMarix Requisition form. Once open click the Printer Icon in the pdf program within the open form.
RML - INVITAE (CombiMatrix) Requisition form
Lead Collection Form
The Hyperlink below will provide a easy to view and printable Lead testing information form. Once open click the Printer Icon in the pdf program within the open form.
Lead Specimen Collection Form
Medical Information Release Authorization
The Hyperlink below will provide a easy to view and printable Medical Release Authorization form. Once open click the Printer Icon in the pdf program within the open form.
Medical Information Release
Microbiology Collection Information
The Hyperlinks below will provide a easy to view and printable Microbiology collection information. Once open click the Printer Icon in the pdf program within the open form.
eSwab Minitip Flocked Collection Kit
MSDS Information
A material safety data sheet or MSDS is a form containing data regarding the properties of a particular substance. An important component of workplace safety, it is intended to provide workers and emergency personnel with procedures for handling or working with that substance in a safe manner, and includes information such as physical data (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, storage, disposal, protective equipment, and spill handling procedures. Click on the links below to reference the MSDS sheets for the materials you may come into contact with specimen collection.
Pathology Slide Request Form
The Hyperlink below will provide a easy to view and printable Pathology Slide Request form. Once open click the Printer Icon in the pdf program within the open form.
Slide Request form
Prenatal Diagnosis Information
The Hyperlink below will provide a easy to view and printable Prenatal Diagnosis Information form. Once open click the Printer Icon in the pdf program within the open form.
First Trimester form
Second Trimester form
PTH / Calcium Graph
The Hyperlink below will provide a easy to view and printable PTH / Calcium Graph to help interpret your patient's results. Once open click the Printer Icon in the pdf program within the open form.
PTH / Calcium Graph
Reference Ranges
The Hyperlinks below will provide an easy to view and printable document. Once open click the Printer Icon in the pdf program within the open form.
Adult Reference Ranges
Age and Gender Specific Reference Ranges
RML Requisitions
The Hyperlink below will provide printer friendly RML requisition. Once open click the Printer Icon in the pdf program within the open form.
Clinical Requisition.
Anatomical Pathology Requisition
Dermatopathology Requisition
RML COVID-19 Requisition
RML COVID-19 Direct Care Requisition with AOEs
Requisition Instructions
The Hyperlink below will provide printer friendly instructions on filling out the RML requisition. Once open click the Printer Icon in the pdf program within the open form.
Requisitions Instructions
STAT Policy for Outreach
The Hyperlink below will provide printer friendly STAT Policy for Outreach document. Once open click the Printer Icon in the pdf program within the open document.
STAT Policy for Outreach
Stone Risk Patient Information
The Hyperlink below will provide printer friendly RML Stone Risk Patient Information form. Once open click the Printer Icon in the pdf program within the open form.
Stone Risk Patient Information form
Stool Collection Containers
The Hyperlink below will provide a easy to view and printable Stool Collection devices for the various microbiology tests performed on stool including occult blood testing. Once open click the Printer Icon in the pdf program within the open form.
Stool Collection Containers
Occult Blood Stool Collection
Supply Requisition Form
RML will provide supplies for your testing needs. Routine deliveries arrive on a scheduled basis. The Hyperlink below will provide a easy to view and printable RML Supply Requisition form. This two page form has General Lab Supplies on page 1 and Histology and Cytology Supplies on page 2. Once open click the Printer Icon in the pdf program within the open form. Supply requests may be faxed directly to our Materials Management Department. Or you may want to try our online Supply Ordering option.
fax numbers:(918) 744-3006 or (888) 833-0528
Download Supply Form 
Online Supply Ordering
Urine Collections, 24hr. Preservatives
The Hyperlink below will provide a easy to view and printable Urine collection and Preservative reference sheets. Once open click the Printer Icon in the pdf program within the open form.
Regional Medical Laboratory