A Test Requisition Form (see sample below) is included with each specimen collection kit. The form indicates which test is to be performed and includes pertinent information about the patient and ordering physician. Payment method and insurance data are also specified. Refer to the following explanations and examples of each section or download a PDF here.

Section 1 - Clinician Information

Verify Clinician's Account Information

This section lists the ordering physician's account number, name, address, telephone, and fax numbers. Please notify Client Services immediately if your account information is incorrect.

Section 2 - Payment Method

Select Payment Method

Place a checkmark in the appropriate box to indicate method of payment. Accounts with established credit may elect the "Bill Clinician"* option. Accounts are subject to a surcharge of 1.5% per month on balances over 30 days, as well as loss of volume discounts.

*Exception: New York state prohibits billing of or acceptance of payment from New York doctors for patient lab services.

Section 3 - Patient Information

Print Patient Information Clearly

Patient or healthcare provider must include the following patient info: first and last name, address, social security number (only if filing to insurance), date of birth, sex, age, and daytime and evening telephone numbers.

Section 4 - Test Information

Order Test(s) and Provide Diagnosis (ICD-9) Codes

Make sure your healthcare provider has placed a checkmark in the box next to the test(s) you wish to order. Please contact your healthcare provider if the tests are not check marked. Additional tests may be ordered by filling in the test number, test name, and specimen types on the right of this section (refer to Commonly Ordered Tests on the reverse side of the form for a complete listing). This information must be provided by your healthcare provider.

Important! Include the date of specimen collection, fasting or non-fasting status, and total volume of urine collected (as applicable). Diagnosis codes (see reverse side of form) must be provided and are required for insurance billing and patient receipts.

Section 5 - Check or Credit Card Information

How to Pay For Tests

Acceptable payment methods are a patient or healthcare professional's credit card (Visa/MC/AMEX/Discover), money order, or check payable to Metametrix, Inc.

A pre-payment discount will apply if you enclose payment in full. The patient or authorized party (parent or responsible party), or clinician must provide check or credit card information or test will not be processed.

Section 6 - Insurance Information

Request Insurance Filing

Metametrix will file medical claims for patients with private insurance only. We are not a participating provider with any insurance company. The patient is responsible for payment of any portion of the test not covered by insurance. Patients should contact their insurance company for coverage information. To qualify for insurance billing**, patients must submit 20% of the list price as payment and include this payment with the specimen.

If filing to insurance, the insurance carrier name, address, claim office telephone number, insurance subscriber, and group number along with the insurance cardholder's name, date of birth, and relation to the patient must al be included. A copy of the front and back of the insurance card must also be submitted with the Test Requisition Form.

Note: We do not file insurance for Cigna, Worker's Compensation, Medicaid, or when Special Combination profiles are ordered. Medicare will not cover tests ordered for screening or investigational purposes.

**Exception - New York State: Metametrix does not bill patients or file medical claims with private insurance, Medicaid, or Worker's Compensation. All tests must include patient payment with submission of specimen. We will accept patient's credit card, check or money order as method of payment. New York law prohibits billing or accepting payment from New York physicians.

Section 7 - Patient Authorization

Signature Required

Patient or authorized party (parent or responsible party) must read, authorize, and sign the Patient or Responsible Party Conditions on the reverse side of the Test Requisition Form.

Example Test Requisition Form