What the FIB-4 requisition is for
The FIB-4 index combines the patient’s age, AST, ALT and platelet count into a score for the likelihood of advanced liver fibrosis. LifeLabs offers it in Ontario as the first step of a two-step primary care pathway, followed by elastography or an ELF score when the FIB-4 is indeterminate or high.
This form is the standard Ontario laboratory requisition, 4422-84, pre-filled for that order. Anything else you need, such as a lipid assessment or HbA1C, can be added on the same form.
Who completes it
The ordering clinician completes and signs it. The patient doesn’t complete any part, but they bring the signed requisition to a LifeLabs patient service centre for the blood draw.
How to fill in the requisition
Clinician and patient details
Enter your name, address, CPSO or registration number, and a contact number for urgent results. For the patient, give the health number and version, sex, date of birth, phone, address, and names as on the OHIP card. The score depends on age, so a missing or wrong date of birth affects the result.
Payer
Check one of OHIP/Insured, Third Party/Uninsured, or WSIB.
Tests
CBC and ALT are already checked, and AST and FIB-4 Score are entered in Other Tests. Add any other tests you need in their sections, one test per line in Other Tests.
Additional clinical information
Give the indication, such as fatty liver on ultrasound, type 2 diabetes with raised ALT, or known chronic liver disease. This helps the lab and anyone copied on the result.
Signature
Sign and date the form. The signature also certifies that the tests aren’t for a registered hospital inpatient or outpatient.
Common reasons it’s delayed or rejected
- Unsigned requisition.
- No payer box checked.
- Date of birth or sex missing.
- Profile names written in Other Tests. LifeLabs asks for individual tests listed separately.
- Pathology, cytology, or a FIT ordered on this form, which the requisition says need their own forms.
Submitting and who pays
The patient takes the signed requisition to a LifeLabs patient service centre. The payer box tells LifeLabs whom to bill. The follow-up ELF score, if you order it, isn’t covered by OHIP and is billed to the patient.