New Sendout Test or Referral Lab Request Form

  • A UVA licensed independent practitioner (LIP) may request addition of new send out tests or referral laboratories to the Medical Laboratory Formulary by filling out the form below. Forms may not be submitted by referral laboratory representatives.
  • Requests for emergent off-formulary testing should be communicated to the laboratory and discussed with the pathologist on call rather than using this form.
  • Approved tests will be added to the Laboratory Formulary, orderable through the UVA EHR. If needed and practical, the referral laboratory may be interfaced with the EHR for automatic transfer of orders and results.
  • This request form requires approval of the department chair or medical director of the requesting department or service, a description of the test and its utility, supporting literature, and disclosure of any conflicts of interest.
  • The request will be reviewed by the Medical Laboratory and the Laboratory Stewardship Committee. The Committee may contact the request submitter for additional information, and the submitter or a delegate may attend the Committee review. Questions about the Committee review should be directed to the co-chairs, James Harrison ( or George Hoke ( If an external online portal is to be used, an IT security review may be required. When the reviews are complete the request submitter will be notified of the outcome.
  • Any incomplete information on the form may delay review and approval.