🖨️ PLEASE PRINT OUT THE REQUISITION FORM FROM YOUR RUPA PATIENT PORTAL (IF AVAILABLE) AND SEND IT BACK WITH YOUR SAMPLES.
If no requisition form is available in your Rupa patient portal, please fill out the blank form and send it with your samples.
These instructions are ONLY for tests ordered using traditional Medicare. For cash-pay orders, fill out your requisition following the instructions HERE.
How to Fill Out Your Requisition
PLEASE PRINT OUT THE REQUISITION FORM FROM YOUR RUPA PATIENT PORTAL. You can throw out the blank requisition form included in your kit.
Please note that your requisition may look slightly different depending on the test you ordered. The information you must fill out will be the same no matter how your requisition is formatted.
❗️The following information IS REQUIRED to properly submit your Medicare claim. If you do not complete this correctly, your order may be reverted to cash pay.
The Billing Type is marked as "Medicare"
ICD-10 codes are listed
Your personal Medicare information is complete and accurate
How Your Completed Requisition Should Look
Please note that your requisition may look slightly different depending on the test you ordered. The information you must fill out will be the same no matter how your requisition is formatted.
