These forms are required to properly capture pertinent patient information that is necessary to result out laboratory testing.

Advance Beneficiary Notice
Required by Medicare as a written notice from a physician, to a Medicare Beneficiary, before laboratory services are furnished in the event that the physician believes that Medicare probably or certainly will not pay for some or all of the services. It allows for the beneficiary to make an informed decision whether or not to receive the services for which they may have to pay out of pocket or through other insurance.

Advance Beneficiary Notice - Spanish
Required by Medicare as a written notice from a physician, to a Medicare Beneficiary, before laboratory services are furnished in the event that the physician believes that Medicare probably or certainly will not pay for some or all of the services. It allows for the beneficiary to make an informed decision whether or not to receive the services for which they may have to pay out of pocket or through other insurance.

Amniocentesis Consent
Required by the Cytogenetics Laboratory when collecting amniotic fluid by amniocentesis for chromosome analysis.

Blood Lead Form
Required by the State of Illinois Department of Public Health (IDPH) for all blood lead samples obtained from children 15 years old and younger. IDPH uses this information for patient follow up and epidemiological studies

Bone Marrow Testing Form
Use to collect clincial information needed for the proper interpretation of bone marrow smears.

Cystic Fibrosis Patient Form
Required by the Molecular Diagnostic Laboratory to collect clinical information required for Cystic Fibrosis testing.

Cytogenetic Patient Information Form
Required by the Cytogenetics Laboratory to collect clinical information for Cytogenetics testing.

Fish Prenatal Panel Request
Required by the Cytogenetics Laboratory to request FISH Prenatal testing.

Patient Standing Order
Required by NorthShore University HealthSystem Laboratory Services to establish Standing Orders for clinical laboratory testing for patients.

Maternal Serum Screening

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