GYN-CYTOLOGY (PAP) REQUISITION FORM

Pap smears must be submitted with this form. All specimens must be properly identified.

  1. Label slide (Conventional Pap) or SurePath specimen container
    • Conventional Pap
      1. Write patient name on bottom 2/3 of frosted end of slide, using pencil
      2. Last name, first name or initial
    • SurePath liquid-based thin layer Pap
      1. Write patient name, physician name, and date on specimen container
  2. Requisition form must be properly and fully filled out:
    • Patient name (last, first, middle initial)
      1. If last name has recently changed, please include former name
    • Patient social security number
    • Physician name
    • Patient date of birth (month, date, year)
    • Clinic/hospital patient ID number (optional)
    • Patient insurance information (not necessary if billed to clinic/hospital)
    • Diagnosis (IDC-9 codes are requested)
    • Test requested
    • Specimen collection date
    • Source of specimen
    • Patient history (will print out on results report)
    • LMP and hx. of abnormal pap, tx., and surgery are required by CLIA
  3. Medicare patients (Advance Beneficiary Notice) a) If you do not have an accurate history of whether the patient has had a pap smear in the last three years, please have the patient sign the Advance Beneficiary Notice that is located in the middle section of the requisition form.
  4. Your clinic/hospital keeps the yellow (back) copy of requisition form, and sends the white (top) copy to the lab, in a bio-hazard bag with the specimen. More than one pap smear specimen may be placed in a bio-hazard bag. Please make sure that each specimen is properly labeled and accompanied by a properly filled out GYN Cytology requisition form.

NOTE: CLIA regulations dictate that the following information must be recorded on the test request form:

  • Patient name
  • Patient date of birth
  • Patient last menstrual period (LMP)
  • Patient history of abnormal pap, treatment., and surgery

contact us

  • WPM Pathology Laboratory
  • 338 N. Front St.
  • Salina, KS 67401
  • 785.823.7201