Lab Services Forms

To order lab supplies, please choose one of the following:

• Online order form

To Add a Test

• Add-on form for CHI Health Laboratory

Advance Beneficiary Notice

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.

• Advance Beneficiary Notice
• Advance Beneficiary Notice - Spanish

EPIC Downtime Procedure

• EPIC Downtime Procedure for Lab Orders

Reference Laboratory Requisitions

Below is a list of approved CHI Health Laboratory requisitions and instructions for completing them.

• Anatomical Pathology (APR) Requisition
• General Lab Requisition - (Green)
• Instructions for completing Anatomical Requisition
• Instructions for completing General Lab Requisition
• Flow Cytometry

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 Creighton University Medical Center - 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

• Release of Information
  

If you have any questions about forms please call (402) 717-5227.