HomeMy WebLinkAboutpublic-health-lab-slipS:\PHLabs\PHL OFFICE\Forms - Submittal\General Requisition Form\Updated Test Req Form 2025\2026.05.14 Public Health Lab Slip
SPECIMEN INFORMATION
BILL TO: Patient SSN:
□ MediCal MEDI-CAL #
□ Alliance ALLIANCE # Referring Physician:
□ CMSP Physician License #
□ Other: Provide copy of Card (front and back) National Provider ID #
DATE OF SERVICE: ICD-10 CODE(S) / DIAGNOSIS:
DATE SPECIMEN TAKEN: PREGNANCY STATUS:
TIME TAKEN:
DISEASE SUSPECTED: PATIENT HISTORY:
REASON FOR TESTING: □ Clearance DATE OF ONSET:
□ Serum □ Stool □ Sputum □ Tissue
□ Plasma □ Urine □ Induced Sputum □ Swab
□ Blood □ CSF □ Aspirate □ Wound □ Other
TESTING ORDERED
ENTERIC BACTERIOLOGY
□ Salmonella
□ Shigella
□ Salmonella typhi
□ Stool Culture
□ E. coli O157
□ STEC
□ Shiga Toxin Gene 1/2 Detection (PCR)
□ Other
BACTERIOLOGY
(Analysis by whole genome sequencing)
□ Aerobic Culture and Definitive ID
□ Anaerobic Culture and Def. ID
□ Bacterial Isolate Definitive ID
□ Neisseria sp. Definitive ID
□ Bordetella pertussis, Definitive ID
□ CRE (carbapenem resistant enterobacteriaciae)
□ Other
MYCOBACTERIOLOGY / AFB
□ AFB Smear / Culture / ID
□ AFB isolate Definitive ID
□ TB Drug Susceptibility
□ M. tuberculosis complex PCR
□ Other
MYCOLOGY/ FUNGAL
□ Fungal Culture and ID
□ Fungal isolate Definitive ID
□ Other
PARASITOLOGY
□ Malaria
□ Other
OTHER TESTS / REQUESTS:
HIV
□ HIV EIA (Oral Fluid) (with reflex confirmation)
□ HIV Screen (serum/plasma) (with reflex confirmation)
□ Confirmatory HIV antibody (Bio-Rad Geenius*)
*will include screening test
SYPHILIS SEROLOGY
□ RPR (with TPPA as reflex confirmation)
□ TPPA Only
□ Other
OTHER IMMUNOLOGY
□ Quantiferon-TB Gold
NAAT (nucleic acid amplification)
□ SARS-CoV-2 (COVID-19) □ Respiratory
□ Influenza A/B Virus Panel
□ Respiratory Syncytial Virus (RSV) (each test to the left)
□ Measles
□ Mumps
□ Bordetella pertussis □ Norovirus
First Name: M.I.:
__________
_________ _
ALAMEDA COUNTY PUBLIC HEALTH LABORATORY
2901 Peralta Oaks Ct, 2nd Floor
OAKLAND, CA 94605
CLIA NO.: 05D2090025
Vici Varghese, Ph.D. HCLD(ABB), Laboratory Director
(510) 382-4300 / FAX (510) 382-4333
Med.Rec.No.:
Last Name:
Acct: Agency:
Address:
Sex/ETH: D.O.B.:
City:
Address:
State:
ZIP:
City: State:
ZIP:
Ordering Clinician:
Phone No: QIC:
SUBMITTER INFORMATION PATIENT INFORMATION
BOLD FIELDS ARE MANDATORY FOR SPECIMEN TESTING
COMPLETE BILLING INFORMATION MUST BE PROVIDED (no billing for mandated services)
Submitters identification of Organism:
Important: Enter your laboratory findings on reverse.
□ Case
□ Confirmation
□ Contact
□ Carrier
□ Other
Treated:
Date of Treatment:
□ No □ Yes
SPECIMEN SOURCE: Drug Therapy: