Equilibrium Diagnostics, LLC

Online Test Requisition

For physician use only. Complete the requisition, attach supporting documentation when applicable, and submit securely to Equilibrium Diagnostics.

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Before you begin: This form collects protected health information. Submit only through this HTTPS page and do not email patient information separately. Fields marked * are required.

Ordering Provider

Provider name *NPI *Practice / facility *Phone / fax *

Patient Information

Last name *First name *Date of birth *Gender Address / city / state / ZIP *Ethnicity Visit type

Billing Information

Insurance verified Relationship Primary insurance ID *Primary group ID Secondary insurance ID Secondary group ID Medicare # Medicaid #

Specimen Collection & Diagnosis Codes

Specimen *Collection date *Collection time Fasting Place Collector name Primary ICD-10 *Secondary ICD-10 Tertiary ICD-10

ICD-10 quick reference

Use the most specific applicable diagnosis code. Common choices: Z79.899 (long-term drug therapy), Z13.1 (diabetes screening), Z13.220 (lipoid screening), Z13.0 (nutritional screening), Z13.29 (endocrine screening), Z13.89 (other screening), R79.89 (abnormal blood chemistry), E78.5 (hyperlipidemia), Z51.81 (therapeutic monitoring), F11.20 (opioid use disorder).

See the complete PDF quick reference

Tests Requested

Select every applicable panel, individual test, and current medication. You may specify additional tests below.

Standard panels (1 SST)

142 — BMP — Na, K, Cl, CO2, Gluc, Crea, BUN, Ca, eGFR9179 — CMP — BMP + Alb, TP, ALP, ALT, AST, TBil, Glob, A/G115 — Electrolytes — Na, K, Cl, CO29175 — Liver Function Panel — ALP, ALT, AST, Alb, TBil, DBil, IBil, GGT, TP173 — Lipid — Chol, HDL, LDL, Trig, VLDL, Ratios9324 — Renal — BMP + Alb, Phos, Mag, LDH, Uric Acid, eGFR

Hematology (1 LAV) & Urinalysis

Specialty panels

Diabetic — A1c, Insulin, GlucoseIron Def. — Ferritin, TIBC, Iron Serum (1 SST)Thyroid — TSH, Free T4, Free T3, Anti-TPO, Anti-TG (1 SST)Hormone — Testosterone, T4/T3, TSH, PSA, Estradiol, Prolactin, Prog, LH, FSH, Insulin, Cortisol, DHEA-S, SHBG, Anti-TPO, Anti-TG (2 SST)Infect. Dis. — Syphilis, HIV 1/2, HCV, HBsAg, HAV, HSV 1 & 2 (2 SST)Wt. Loss — Lipase, Amylase, A1c, CBC, TSH, TestosteroneNeurology — CBC, CMP, A1c, TSH, Free T4, B12, Folate, Vit D, Mag, CRP, Ferritin, Lipid, Homocysteine, Intact PTH, ApoA1, ApoB, Uric Acid, Anti-TPO, Anti-TG (2 SST)

Wellness panels

EXT. MALE WELLNESS (2 SST, 2 LAV)EXT. FEMALE WELLNESS (2 SST, 2 LAV)BASIC MALE WELLNESS (2 SST, 2 LAV)BASIC FEMALE WELLNESS (2 SST, 2 LAV)

Toxicology / therapeutic drug monitoring

Molecular / infectious disease panels

Other / write-in tests or clinical notes

Supporting Documentation

Attach available demographics, insurance card, medical necessity documentation, SOAP notes, or visit history. Accepted: PDF, JPG, PNG, DOC, DOCX. Maximum 10 MB per file; up to five files.

Supporting files

Certification & Consent

Patient signature (typed) Physician signature (typed) *Date *

Test Requisition

Online Test Requisition

Standard panels (1 SST)

Hematology (1 LAV) & Urinalysis

Specialty panels

Wellness panels

Toxicology / therapeutic drug monitoring

Individual chemistry (1 SST unless noted)

Individual infectious disease serology

Molecular / infectious disease panels

Current medications

(210) 903-0551

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