Completing a Test Requisition Form

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. An incomplete form may prevent us from processing your order, which can delay your test results. 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. Select "Payment Enclosed (Bill to Insurance)" if you would like Metametrix to file a courtesy claim on your behalf to your insurance company or choose "Payment Enclosed (DO NOT Bill to Insurance)." Clinician accounts with established credit may elect the Bill Clinician* option. Clinician signature is required. 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, middle initial, address, date of birth, height, weight, gender, email, and daytime and evening telephone numbers.

Section 4 - Test Information

Order and Checkmark Test(s) you are requesting

Record the date specimen is collected. Place a checkmark in the box next to the test(s) you wish to order. Additional tests may be ordered by filling in the test number and test name in section 5.

Important! Include the date of specimen collection, fasting or non-fasting status, and total volume of urine collected (as applicable).

Section 5 - Additional Tests

Please list the test number and test name for additional test ordered.

Section 6 - ICD-9 Codes

ICD-9 codes are required for insurance billing and patient receipts. Please visit www.metametrix.com/icd9 for a list of the codes.

Section 7 - Check or Credit Card Information

How to Pay For Tests

Acceptable payment methods are Visa, Mastercard, American Express, Discover, money order, or check payable to Metametrix, Inc. Canada and international residents may pay by credit card or wire transfer only.

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 8 - Responsible Party Insurance Information

PrePay Advantage: Courtesy Insurance Filing Program

Metametrix offers a courtesy insurance filing program for all patient prepaid test submissions. Metametrix will submit insurance claims as a courtesy for patients that include full payment at the "Patient Prepay" price with specimen submission. This does not guarantee reimbursement from the insurance provider. If the claim is denied, the patient may then provide missing information or appeal rejection directly with their insurance provider, if needed. Metametrix does not negotiate rates and all further activity regarding the claim is the responsibility of the insured. Learn more about PrePay Advantage here.

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 Worker's Compensation and Medicaid. Medicare will not cover tests ordered for screening or investigational purposes.

Section 9 - Patient or Responsible Party Signature

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