Lab Services Forms
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To order lab supplies, please choose one of the following:
- CHI Health Laboratory Supply Form (Please add your client code)
- CHI Health Laboratory Supply Form (For Nursing Homes, Assisted Living Facilities, Home Health Agencies)
- Online order form
To add a test
An Advance Beneficiary Notice form is submitted if patient is of Medicare age, does not have an approved diagnosis, and therefore must pay the test's cost out-of-pocket. The physician's office completes this form and the patient must sign it prior to the test.
Below is a partial list of approved Alegent Health Reference Laboratory Requisitions and instructions for completing them. When these requisitions are presented to the patient service centers (PSC) and the Diagnostic Centers (DC) the patient will receive reference laboratory pricing.
- Flow Cytometry
- NextGen EMR Requisition (LOS)
- NextGen EPM Requistion
- Physician Office EHR Requisitions
- Web Connect Requistion
CHI Health manual lab requisition examples and instructions for completing them.
- Anatomical Pathology (APR) Requisition
- General Lab Requisition - (Green)
- Instructions for completing Anatomical Requisition
- Instructions for completing General Lab Requisition
Lead, Urine, Alpha Fetoprotein, Quad Screen forms
Medical Records Release form
Patients may access their laboratory results by completing a medical records Release of Information form. Forms can be mailed to the address below or faxed to 402-398-6016:
CHI Health Bergan Mercy
Attention: Release of Information
7500 Mercy Road Omaha, NE 68124
Note: Patients can expect to receive results within 30 days of our receipt of the form. If you have questions, or you would like to receive a release of information form by mail, please call 402-717-5227
If you have any questions about forms please call (402) 717-5227.