What the 4422-84 is for
The requisition orders tests at licensed community laboratories in Ontario. It lists common biochemistry, hematology, immunology, microbiology and hepatitis tests as checkboxes, with an “Other Tests” area for anything else. The current edition is 4422-84 (2026/04). It isn’t the form for cervical screening, FIT, pathology or Public Health Ontario testing, which each have their own requisition.
Who completes it
The requisitioning physician or practitioner completes the clinician, patient and test sections and signs it. The laboratory completes the specimen collection time and date and the laboratory use boxes.
How to fill in the requisition
Clinician and patient details
Enter your name, address, CPSO or registration number and a number for urgent results. Use the patient’s names exactly as they appear on the OHIP card, with health number, version code, sex, date of birth, address and phone. Add a copy-to clinician if another provider should get the results.
Payment type and clinical information
Tick one payment box: OHIP/Insured, Third Party/Uninsured or WSIB. For an out-of-province patient, give the province and their health number. Use the additional clinical information box for the diagnosis or reason for testing, which helps the lab interpret results.
Tests
Tick tests in each section. For glucose, choose random or fasting. Viral hepatitis allows one panel only, so order individual hepatitis tests in the “Other Tests” lines instead. Microbiology swabs and cultures need the source specified. For neonatal bilirubin, give the child’s age in days and hours and phone numbers for you and the patient.
PSA and vitamin D
Both carry insured and uninsured options on the form. Tick insured PSA only for suspected or diagnosed prostate cancer, and insured vitamin D only for the listed conditions. Asymptomatic screening goes under uninsured, and the patient pays the lab.
Therapeutic drug monitoring and other tests
For drug levels, name the drug and give the time collected, time of last dose and time of next dose. Write one test per line in “Other Tests”.
Signature
Sign and date the form. Your signature certifies the tests aren’t for registered hospital inpatients or outpatients.
Common reasons it’s rejected or delayed
- Patient names that don’t match the OHIP card, or a missing version code.
- No payment type ticked.
- Insured PSA or vitamin D ticked for a patient who doesn’t meet the printed criteria.
- A FIT, Pap or pathology specimen ordered on this form.
- A swab or culture with no source.
- No signature or no urgent results contact number.
Submitting and who pays
The patient takes the requisition to a licensed community laboratory. The payment box tells the lab who to bill: OHIP for insured tests, the patient or a third party for uninsured ones, or WSIB for a work injury claim. Medulla can suggest this requisition from the lab orders in the visit plan.