Ontario Lab Requisition Form 4422-84: How to Complete

This is Ontario's standard order form for community (non-hospital) laboratory tests, completed from the fillable PDF or printed from an OntarioMD-certified EMR. It identifies the ordering clinician and patient, shows who pays, and lists common tests by section, with PSA and vitamin D coverage criteria printed on the form. Labs can only process and bill requisitions that are complete, legible and authorized, and each is valid for six months.

Who completes it

The ordering clinician completes the whole form: practitioner details, billing box, patient identification as on the OHIP card, tests and signature. Only authorized practitioners, such as physicians, nurse practitioners and midwives, can order OHIP-covered community tests, and a physician can delegate signing authority to an employee.

How to fill it in

Requisitioning Clinician / Practitioner

Enter your name and address, clinician/practitioner number, CPSO or other registration number, and a contact number the lab can use for urgent results. If these come pre-printed from your EMR, check that none are missing: the Schedule of Benefits says incomplete, unauthorized or illegible requisitions cannot be processed by the lab or paid. Tests ordered for OHIP-insured patients by physicians lawfully practising in another province can be claimed if the requisition is properly completed.

Check one: OHIP/Insured, Third Party / Uninsured, WSIB

Tick one box to show who pays: OHIP/Insured only for tests OHIP covers for this patient, Third Party / Uninsured when another payer or the patient pays, or WSIB. Below it, Additional Clinical Information takes relevant details such as the diagnosis, and Copy to lets you name another clinician or practitioner, with their address, to receive a copy of the results.

Patient information (as per OHIP card)

Enter the health number and version code, sex, date of birth, province (or another provincial registration number) and the patient's telephone number. Write the last name and first and middle names exactly as they appear on the OHIP card, plus the full address with postal code. The service date used for lab claims is the day the patient or specimen arrives at the collection centre or laboratory with the requisition.

Biochemistry

Tick the tests needed: glucose (random or fasting), HbA1C, creatinine (eGFR), uric acid, sodium, potassium, ALT, alkaline phosphatase, bilirubin, albumin, urine albumin/creatinine ratio and chemical urinalysis. Lipid Assessment covers cholesterol, HDL-C, triglycerides, calculated LDL-C and the cholesterol/HDL-C ratio; order single lipid tests under Other Tests. Neonatal bilirubin needs the child's age in days and hours, your telephone number and the patient's 24-hour number; therapeutic drug monitoring needs drug names and collection, last-dose and next-dose times.

Hematology and Immunology

Hematology offers CBC and prothrombin time (INR). Immunology lists the urine pregnancy test, mononucleosis screen, rubella, the prenatal panel (ABO, RhD and antibody screen, with titre and identification if positive) and repeat prenatal antibodies. Under the Schedule of Benefits, human chorionic gonadotropin or beta-subunit testing is performed only when specifically requested, so name it under Other Tests if that is what you need.

Microbiology ID & Sensitivities (if warranted)

Tick the specimen type: cervical, vaginal, vaginal/rectal group B strep, chlamydia, GC, sputum, throat, wound, urine, stool culture, stool ova and parasites, or other swabs and pus. Chlamydia, GC, wound and other swab entries need the specimen source written in. The Specimen Collection box beneath this column records the collection time, on a 24-hour clock, and the date in yyyy/mm/dd format.

Viral Hepatitis (check one only)

Tick a single panel: acute hepatitis, chronic hepatitis, or immune status/previous exposure. For immune status, specify hepatitis A, B or C. If you need specific hepatitis tests rather than one of these panels, the form says to order individual hepatitis tests in the Other Tests section instead of ticking more than one panel.

Prostate Specific Antigen (PSA) and Vitamin D (25-Hydroxy)

For PSA, tick total or free PSA and specify one indication: insured for suspected prostate cancer (family history, race, physical examination, symptoms) or diagnosed prostate cancer under monitoring or follow-up, or uninsured asymptomatic screening paid by the patient. For vitamin D, tick insured only if the patient meets OHIP criteria: osteopenia, osteoporosis, rickets, renal disease, malabsorption syndromes or medications affecting vitamin D metabolism. Otherwise tick uninsured, and the patient pays.

Other Tests: one test per line

Write any test not listed elsewhere, one per line, such as individual lipid or hepatitis tests. If a test is not insured for this patient, the Schedule of Benefits says to write the word uninsured beside the test name, and makes the ordering practitioner responsible for telling the patient they are expected to pay. Tests on specimens sent outside Ontario are not insured without prior ministry approval.

Certification and Clinician/Practitioner Signature

Sign and date under the printed certification that the tests ordered are not for registered in-patients or out-patients of a hospital. Labs accept a wet signature, a digitized signature printed by certified EMR software, or an OLIS-compliant e-requisition. A rubber stamp or a signature image not generated by a certified EMR is acceptable only with the initials or signature of the person who holds signing authority.

Common mistakes

Using a requisition more than six months after it was authorized; expired, incomplete, unauthorized or illegible requisitions cannot be processed or claimed by the lab.
Ticking Insured for PSA screening or vitamin D in a patient who does not meet OHIP criteria; those tests must be marked uninsured and paid by the patient.
Not telling the patient a test is uninsured; the Schedule of Benefits makes the ordering practitioner responsible for informing them that they are expected to pay.
Adding cytology, cervical screening HPV, pathology, FIT or Public Health Laboratory tests to this form; each requires its own separate requisition.
Writing standing orders without a frequency; repeat tests must state how often (for example weekly or monthly) and need a new requisition every six months.
Relying on a rubber stamp or a non-EMR signature image alone, without the initials or signature of the person with signing authority.

Submitting and payment

How to submit it: The patient takes the signed paper or EMR-printed requisition to a community laboratory or specimen collection centre, or the order is transmitted as an OLIS-compliant e-requisition. Each requisition is valid for six months from the date it was authorized.
Who pays: The community laboratory claims insured tests from OHIP and may not share those fees with the ordering practitioner, while the patient pays for tests marked uninsured, such as asymptomatic PSA screening.

Good to know

For repeat or standing orders, state the frequency (for example weekly or monthly); a new requisition is needed every six months if the test is to continue.
Some tests are insured only in set circumstances, such as AST when ordered by or on the advice of a physician with expertise in hepatic disorders, and NT-proBNP only for suspected heart failure.
The certification above the signature confirms the tests are not for registered hospital in-patients or out-patients; Ontario advises hospital patients to have tests done at the hospital to avoid charges.
The Central Forms Repository lists the form in English only. The 2026/04 edition rewords the PSA section, effective April 16, 2026, without changing what OHIP covers.

Get the official form

Download the current version from the source each time; forms change without notice.

Laboratory Requisition - Requisitioning Physician / Practitioner

Official page PDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How long is an Ontario lab requisition valid?

Six months from the date it was authorized. The Schedule of Benefits for Laboratory Services sets this limit for patient safety, and labs cannot process or claim incomplete, unauthorized or illegible requisitions. For repeat tests, state the frequency on the requisition and issue a new one every six months if testing continues.

Who can sign an Ontario lab requisition?

An authorized practitioner, such as a physician, nurse practitioner or midwife, or a physician's employee with delegated signing authority who is not an owner or employee of a community lab. Labs accept wet signatures, certified-EMR digitized signatures and OLIS-compliant e-requisitions; a rubber stamp or non-EMR signature image also needs the initials or signature of the person with signing authority.

Does OHIP cover vitamin D and PSA tests?

Only in set circumstances. Vitamin D (25-hydroxy) is insured for osteopenia, osteoporosis, rickets, renal disease, malabsorption syndromes or medications affecting vitamin D metabolism. PSA is insured for suspected prostate cancer or monitoring and follow-up of diagnosed prostate cancer, but not for asymptomatic screening. Otherwise tick the uninsured box and tell the patient they will pay.

Which lab tests need a separate requisition in Ontario?

The form says cytology, Ontario Cervical Screening Program HPV and cytology tests, histology and pathology, the ColonCancerCheck FIT test, and tests performed by the Public Health Laboratory each need their own requisition. Non-invasive prenatal testing is insured only through the Prenatal Screening Ontario requisition that the laboratory provides.