Lab Requisition Builder
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wellpathprime.com
5/19/2026
Laboratory Requisition Form
Patient Name (Last, First, MI)
Ordering Provider
Date of Birth
NPI Number
Biological Sex
Date Ordered
Patient ID / Chart #
Practice / Clinic Name
Clinical Indication / ICD-10
Biomarker Panel — 46 markers selected — LabCorp
Cardiovascular Health
| Marker | CPT | LC | |
| ApoB | 82172 | 167015 | |
| HDL Cholesterol | 80061 | 221010 | |
| LDL Cholesterol | 80061 | 221010 | |
| RDW | 85025 | 005009 | |
| Total Cholesterol | 80061 | 221010 | |
| Triglycerides | 80061 | 221010 |
Metabolism
| Marker | CPT | LC | |
| ALP | 80053 | 322000 | |
| ALT | 80053 | 322000 | |
| Fasting Glucose | 80053 | 322000 | |
| Fasting Insulin | 83525 | 004333 | |
| HbA1c | 83036 | 001453 | |
| HOMA-IR | Calc. | Calc. | |
| Testosterone | 84403 | 004226 | |
| Uric Acid | 84550 | 001057 |
Inflammation
| Marker | CPT | LC | |
| Basophils | 85025 | 005009 | |
| Eosinophils | 85025 | 005009 | |
| Lymphocytes | 85025 | 005009 | |
| Monocytes | 85025 | 005009 | |
| Neutrophils | 85025 | 005009 | |
| NLR | Calc. | Calc. | |
| WBC | 85025 | 005009 |
Immune & Kidney
| Marker | CPT | LC | |
| Albumin | 80053 | 322000 | |
| BUN | 80053 | 322000 | |
| Creatinine | 80053 | 322000 | |
| eGFR | 80053 | 322000 | |
| Hematocrit | 85025 | 005009 | |
| Hemoglobin | 85025 | 005009 | |
| MCH | 85025 | 005009 | |
| MCHC | 85025 | 005009 | |
| MCV | 85025 | 005009 | |
| Protein (Serum) | 80053 | 322000 | |
| Red Blood Cell Count | 85025 | 005009 |
Hormone Balance
| Marker | CPT | LC | |
| Calcium (Serum) | 80053 | 322000 | |
| TSH | 84443 | 004259 |
Recovery
| Marker | CPT | LC | |
| AST | 80053 | 322000 | |
| Creatine Kinase | 82550 | 001362 | |
| GGT | 82977 | 001958 | |
| Potassium | 80053 | 322000 | |
| Sodium | 80053 | 322000 |
Endurance
| Marker | CPT | LC | |
| Iron | 83540 | 001339 | |
| Platelet Count | 85025 | 005009 | |
| TIBC | 83550 | 030825 |
Sleep-Related
| Marker | CPT | LC | |
| Ferritin (Serum) | 82728 | 004598 | |
| hsCRP | 86141 | 120766 | |
| Transferrin Saturation | Calc. | Calc. | |
| Vitamin D | 82306 | 081950 |
Order Plan — LabCorp
Panel Orders:
Standalone Orders:
Fasting required (8+ hrs): Fasting Glucose, Fasting Insulin, HOMA-IR, Triglycerides. Fasting preferred: Homocysteine. Cortisol and Testosterone: morning draw (8-10am) recommended for standardized results.
* Calc. = Derived value (HOMA-IR from Glucose x Insulin; NLR from Neutrophils / Lymphocytes). Standard panels: CBC (85025), CMP (80053), Lipid Panel (80061), Iron+TIBC+Ferritin+Transferrin Sat. CPT codes are for reference only; billing is the sole responsibility of the ordering provider.
Provider Signature
Date
For Provider Use Only