How to Fill Out and Submit the LifeSouth Therapeutic Phlebotomy Order

The LifeSouth therapeutic phlebotomy order form is a one-page PDF that a physician, physician assistant, or nurse practitioner must complete and sign before a patient can be scheduled for a draw at any LifeSouth donation center. The form captures the patient’s demographics, the ICD-10 diagnosis driving the order, the minimum hemoglobin level LifeSouth should respect, and the frequency of visits. Once signed, it goes to LifeSouth by fax or email, and the center will not draw blood from a patient who arrives without a completed order on file.¹

Where to Get the Current Form

The current version is posted on the LifeSouth website as a downloadable PDF.² Providers can also request a copy from their local LifeSouth center. There is a separate in-hospital version for procedures performed inside a hospital setting, which uses a different fax number.³ The outpatient form is what the rest of this guide covers.

Who Can Sign It

The order must be completed by a physician or an advanced practice provider such as a PA or NP. Providers cannot write the order for themselves or for an immediate family member, and LifeSouth will reject any order that violates that restriction.²

Patient Information

Every field in the patient section needs an entry. Blanks slow processing and can send the form back.² You will need:

Full name (last, first, middle)
Sex and date of birth
Phone, email, and a full mailing address including city, state, and zip

Two clinical screening questions sit directly below the demographics. The first asks whether the patient has any medical condition that could increase the risk of an adverse reaction during the draw. The second asks about known infectious diseases, including viral hepatitis, HIV, HTLV, syphilis, and West Nile virus. If you mark “yes” on the adverse-reaction question, the order has to be reviewed and approved by LifeSouth’s medical director personally rather than by a designee.²

Choosing the Indication

The form pre-prints the most common indications with their ICD-10 codes as checkboxes. Pick the one that matches the patient’s diagnosis:²

D75.1 — secondary polycythemia or erythrocytosis
Testosterone replacement therapy (listed separately for TRT-driven erythrocytosis)
E83.110 — hereditary hemochromatosis
D75.0 — familial polycythemia or erythrocytosis
E83.118 or E83.119 — other or unspecified hemochromatosis, including acquired and secondary forms
E80.1 — disorders of porphyrin metabolism, including porphyria cutanea tarda
R79.89 — other abnormal blood chemistry, covering elevated ferritin, hemoglobin, or iron
D45 — polycythemia vera

Accuracy here matters beyond medical correctness. Healthcare facilities are required to use ICD-10 for diagnosis reporting on HIPAA-covered transactions, and the wrong code can create billing problems or flag the order during review.⁴

Setting the Clinical Parameters

This is the section that governs what actually happens at each visit, and it is where incomplete orders most often stall. You are setting two things: the minimum hemoglobin below which LifeSouth should not draw, and how often the patient should come in.

Hemoglobin Minimum

LifeSouth tests hemoglobin at every visit and will not proceed if the patient is below the minimum you specify. If you leave the field blank, these defaults apply:⁵

Male patients: 13.0 g/dL
Female patients: 12.5 g/dL
Hereditary hemochromatosis: 11.0 g/dL, which is also the absolute minimum LifeSouth will accept

One limitation worth flagging on the form if it affects your patient: LifeSouth can only measure hemoglobin at the time of the draw. The center cannot monitor ferritin, hematocrit, or other lab values, so an order that depends on those markers for go/no-go decisions falls outside what LifeSouth can accommodate.⁵ If the treatment plan requires ferritin tracking, the referring clinic has to handle that in-house.

Volume and Frequency

Each session removes 500 mL of whole blood, plus or minus 10 percent. That volume is fixed and the form does not offer alternatives. You specify how often the patient should return, with the understanding that LifeSouth enforces a floor of at least seven days between draws regardless of what the order says.² Beyond that minimum spacing, LifeSouth does not independently track frequency; the patient and clinic are responsible for scheduling the visits at the prescribed intervals.

Provider Signature

At the bottom, the ordering provider prints their name with credentials, lists an office phone number and address, then signs and dates the form.² The signature is what turns the form from a worksheet into a valid medical order. An unsigned form will not be processed.

How to Submit It

Send the completed, signed form to LifeSouth by either channel printed on the form:²

Fax: 888-286-0179
Email: MEDICALOFFICE@LIFESOUTH.ORG

If you fax, keep the confirmation page. For hospital-based procedures, use the in-hospital form and its separate fax number, 352-224-1778.³

What Happens Next

LifeSouth asks you to allow at least two business days from receipt of a complete order for processing. A nurse or the medical director reviews the clinical details and confirms the patient is eligible. If you flagged an adverse-reaction risk, the medical director must sign off personally rather than delegating.²

Once approved, a LifeSouth representative contacts the patient to schedule the first appointment. The patient should bring a valid photo ID and be ready to have vital signs checked before the draw. Patients must have normal vital signs and be in otherwise healthy, stable condition at check-in; staff can postpone the session if something is off.¹ Patients also need to weigh at least 110 pounds to be eligible for a standard draw.² There is no charge for the procedure.⁶

Why Orders Get Rejected or Delayed

Most problems trace back to the same handful of mistakes, all drawn from the instructions printed on the form itself:²

Blank fields anywhere in the patient or clinical sections
The order was signed by someone other than a physician, PA, or NP
Self-prescribing for the provider or an immediate family member
The patient weighs less than 110 pounds
The order asks LifeSouth to monitor ferritin, hematocrit, or other values the center cannot test on-site
The standing order has passed its one-year expiration

Renewing a Standing Order

Standing orders are valid for one year from the request date printed on the form, and there is no automatic renewal.² The referring provider must submit a new, fully completed form before the expiration to avoid a gap. Patients on long-term phlebotomy for conditions like hereditary hemochromatosis or polycythemia vera should coordinate with their provider’s office well ahead of the one-year mark so the new order clears processing before the next scheduled draw.

1
LifeSouth Community Blood Centers. Important Notes on Therapeutic Phlebotomy Orders
2
LifeSouth Community Blood Centers. Therapeutic Phlebotomy Order
3
LifeSouth Community Blood Centers. In-Hospital Therapeutic Phlebotomy Order
4
Centers for Medicare & Medicaid Services. ICD-10
5
LifeSouth Community Blood Centers. Therapeutic Phlebotomy Order
6
LifeSouth Community Blood Centers. TRT and Therapeutic Phlebotomy: Provider Webinar