Completing the Request form
Please attach a copy of the front and back of the patient's insurance card with the requisition and provide the patient's complete billing address, phone number, and Medicare number in the billing information box on the RML test requisition form when Medicare is to be billed. Also, we ask that an appropriate ICD-9 code be supplied by the ordering physician and a completed and signed Advanced Beneficiary Notice (ABN) accompany the patient's test request. For questions regarding ICD-9 coding and/or other issues concerning Medicare, please contact our billing department or refer to the Oklahoma/New Mexico Medicare website at www.trailblazerhealth.com. Valid ABN forms are available at no charge to our clients and can be obtained by calling RML Client Services at (918) 744-2500, option 3, or (800) 722-8077.
The Medicare License number for RML is 731131608C.
Our billing representatives are available Monday through Friday, 8:30am to 4:30pm, to discuss any billing questions you may have. They can be reached by phone, (918) 744-2164 or (800) 331-9102, by fax, (918) 744-2174, or by email, firstname.lastname@example.org.
- Last Name, First Name, Middle Name or Initial - Always use the legal name (not nicknames please) as this is crucial to insurance filing. The name on the requisition should match the name on the specimen exactly.
- Sex - Normal result ranges may vary between sexes.
- Patient's Social Security Number - Ties account and medical history records together.
- Date of Birth - RML reports age specific reference ranges for many tests.
- Date - Specimen collection date.
- Time - Specimen collection time.
- Requesting Physician - Complete name (first and last) of ordering doctor- not clinic name, group name, etc.
Please Circle Physician's Number - Requisitions with client specific information.
- Consulting Physician - In order for a consulting physician to obtain a report, please supply the complete name (first and last) of the consulting doctor and contact information- not clinic name, group name, etc.
RML has developed two new requisitions: Clinical Testing and Cytology/Anatomic Pathology Testing.
On the Clinical Requisition - Mark requested tests with an "X" as clearly as possible in the center of the provided space next to the test. Any test not listed can be written in the space provided labeled "Other Tests Not Listed".
On the Cytology/Anatomic Pathology - Please list the source and complete the information as indicated for the area testing. Additional clinical information may be written in the space provided. Cytology and Anatomical Pathology information is listed on the lower portion of the older requisition versions.
Consulting or Referring Physicians
To request results for consulting or referring physicians please complete the box on the requisition under Patient Information labeled “Consulting Copy to Physician(s)”. Please provide the first and last name and address of the other physician(s).
The patient's chart copy will be mailed if the physician is not a client. If the physician is a client, a courier will deliver the copy.
Copies will not be sent to patients unless an authorized Release and Consent Form is signed and on file. Patients may either pick up results or receive results in the mail. Attorneys may receive copies of court-ordered reports when the patient has signed a Release and Consent Form.
Requesting Results to be Called or Faxed
To request results be called or faxed, check the appropriate box and fill out the phone or pager number and/or the fax number in the space provided under the RML logo at the top of the requisition.
To request results be faxed, please complete the part of the requisition in the top right corner of the requisition. Check the box marked “Fax Results” and ordering physician's office will be faxed. If a different number is to be notified, indicate the different phone number in the provided space next to the checked box at the top of the requisition. When noted on the requisition to receive results by fax, the test(s) will be performed on a routine basis and will be faxed upon completion.
Note a “fax or call” request should not be used in lieu of a STAT or for results needed on a STAT basis. If STAT results are required, you must mark the “STAT” box on the requisition.
Finishing out the Requisition Form
After the test requisition form is completed, tear off the back copy and keep for your records. Send the original to RML with specimens or the patient.