Surgical Pahtology Form

SURGICAL PATHOLOGY REQUEST FORM

A request form must accompany each specimen. To provide accurate service, we ask that you fill out the form completely as described below. Enter accurate demographic information and ALL pertinent clinical data to ensure proper correlation of the specimen with any prior cytology or surgical material. This enables the Pathologist to better evaluate the case. Keep office copy for your files. Only one requisition needed per patient with multiple specimens.
Roll your mouse over the numbered sections to view a brief description/instructions.

Enter your institution’s code, requesting physician’s name and UPIN code. Check the block to indicate how this is to be billed: Bill the patient Bill Medicare/Medicaid (provide further information) Bill Commercial Insurance
Enter patient demographics. It is very important to include all requested information if we are to bill the patient or their insurance.

Enter the patient’s Medicare, Medicaid, or commercial insurance in the gray shaded area marked “Billing Information.” For insurance billing, this must be filledout completely.
Enter Clinical Information including previous specimens, whether it be the specimen number or date. Please enter as much information as possible so that proper evaluation can be performed. Provide an appropriate diagnosis/ICD9 to indicate medical necessity. A written description is accepted, although an ICD9 is preferred.
List tissues and their sources; Only one request is required for patients with multiple surgical specimens. Please list numerically in section #8A for tissue and #8B for fluids. (BE SURE TO INCLUDE COLLECTION DATE.)
All Medicare patients must be advised of the current screening limitations. If the patient has exceeded the limitation of one pap per every three years, yet wants an additional pap performed, then the patient must sign the Advance Beneficiary Notice.

Enter your institution’s code, requesting physician’s name and UPIN code.
Check the block to indicate how this is to be billed: Bill the patient Bill Medicare/Medicaid (provide further information)
Enter patient demographics. It is very important to include all requested information if we are to bill the patient or their insurance.
Always give date of birth of the patient.
Enter the patient’s Social Security number. This helps to correctly identify the patient for proper billing.
Enter the patient’s Medicare, Medicaid, or commercial insurance in the gray shaded area marked “Billing Information.” For insurance billing, this must be filledout completely.
Provide an appropriate diagnosis/ICD9 to indicate medical necessity. A written description is accepted, although an ICD9 is preferred.
List tissues and their sources; Only one request is required for patients with multiple surgical specimens. Please list numerically in section #8A for tissue and #8B for fluids. (BE SURE TO INCLUDE COLLECTION DATE.)
Enter clinical information. Please include information regarding any previous specimens, whether it be the specimen number or date. Please enter as much information as possible so that a proper evaluation can be performed.
Enter Clinical Information including previous specimens, whether it be the specimen number or date. Please enter as much information as possible so that proper evaluation can be performed.
All Medicare patients must be advised of the current screening limitations. If the patient has exceeded the limitation of one pap per every three years, yet wants an additional pap performed, then the patient must sign the Advance Beneficiary Notice.

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