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
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
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
- 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.