DIAGNOSTIC „

New York Client Services
(800) 447-5816
fax: (212) 689-9532
PATIENT LAST ___________________ FIRST __________________ MIDDLE _____________
PATIENT
1A
DIAGNOSTIC
www.integratedoncology.com
Highlighted fields are required.
„ Male
„ Female
Date of Birth
_______ / _______ / _______
___________________________________________________________________________ Social Security # _____________________________________________________________
City ____________________________________ State _____ Zip ____________________ Lab # ______________________________ Hospital # ______________________________
1B
1A
Address ___________________________________________________________________ Home Phone _________________________ Work Phone ____________________________
CLIENT
Referring Physician __________________________________________________________ Treating Physician __________________________________ Phone # ___________________
Referring Physician Phone/pager _________________________________________________
NPI # ______________________ Taxonomy # (NPI Specialty Code) _____________________ Physician/Authorized Signature _______________________________________________________
SPECIMEN AND CLINICAL INFORMATION
Specimen Information
TESTS AND SERVICES, CONTINUED
Molar Pregnancy
Hospital status when sample collected:
… Inpatient
… Outpatient
… Non-hospital
… DNA Ploidy/S-Phase & p57 (IHC)
… DNA Ploidy/S-Phase
… If diploid, reflex to p57 (IHC)
Body Site/
ID#(s): ________________________ Descriptor: _______________________________
Collection Date: ____________ Time: ____________ Send Date: ___________________
Lymph Node and Bone Marrow Micrometastases Detection
NOTE: If multiple blocks are submitted, the best block will be selected.
… Paraffin Block: (attach H&E with each submitted block) … Formalin … Other: _________
Required for Breast Cancer: Time to Tissue Fixation:_________ Tissue Fixation Time: _________
Integrated Oncology pathologist will select antibodies (range 1–4 per block) that are medically
necessary depending on the tumor type:
… Breast … Melanoma … Neuroblastoma … Other: ___________________________
… Slides __________________ … Smears ______________
… Bone Marrow _____________ … Peripheral Blood/Stem Cell Product_________________
… Urine: Voided Urine ________ … Bladder Washing_______ … Wet Tissue
Return Material To: … Ordering Client
… Other: Name/Address (indicate below)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Clinical Information-Diagnosis/Signs/Symptoms in ICD-CM format in effect at Date of Service (Highest Specificity Required)
_________________________________________________________________________
_________________________________________________________________________
Clinical Data: (attach clinical history and pathology reports)
TESTS AND SERVICES
UroVysion® FISH
… UroVysion® FISH (MD Review) … UroVysion® FISH (PhD Review)
Urine Collection Method: … Voided … Catherized … Bladder Wash
Infectious Agents (IHC)
… Adeno
… CMV
… H. pylori … HSV
… EBV (LMP1)
… Parvovirus*
… HBcAg … HBsAg
… P. carinii … TOXO
… HCAg
… VZV
In Situ Hybridization (ISH)
… EBV (EBER)
… PML (JC)
HPV Tissue Testing
… HPV Screen
… HPV Subtype Only
… KAPPA
… LAMBDA
… HPV if Screen Positive, do Subtype (6/11, 16/18, 31/33)
… HPV Screen & Subtype
Tumor Analysis
Immunohistochemical tumor analysis with professional interpretation. Integrated Oncology pathologist
will select antibodies (range 1–25) that are medically necessary depending on the diagnosis under
consideration:
… Lymphoma vs. reactive hyperplasia
… Acute leukemia
… Adenocarcinoma vs. mesothelioma
… Bladder vs. prostate carcinoma
… Carcinoma of unknown primary site
… Carcinoma vs. melanoma
… Germ cell tumor
… GIST
… Hepatoma/cholangio vs. met. carcinoma
… Hodgkin vs. NHL
… Lung vs. breast
… Lymphoma phenotype
… Lymphoma vs. carcinoma
… Molar vs. non-molar pregnancy
… Neuroendocrine neoplasm
… Paget’s disease vs. melanoma vs. SqCC
… Pituitary neoplasm
… Plasma cell neoplasm
… Prostate carcinoma vs. adenosis
… Small cell vs. non-small cell carcinoma
… Small round cell tumor (e.g., Ewing’s, PNET)
… Soft tissue tumor
… SqCC vs. melanoma vs. AFX
… Squamous cell vs. adenocarcinoma of lung
… Undifferentiated tumor
Consultative Services
(Send pathology report)
… Pathology consultation and report on referred material requiring slide preparation
… Pathology consultation and report on referred slides
… IHC staining with brief summary interpretation
… Technical component (antibody stain) only
Individual Antibodies
Specify: (The most current Antibody Library is available at www.integratedoncology.com/ab)
_________________________________________________________________________
_________________________________________________________________________
Provisional/Differential Diagnosis(es): _______________________________________________
*Investigational Use Only. UroVysion® is a registered trademark of Abbott Laboratories.
Integrated Oncology is a brand used by both Accupath Diagnostic Laboratories, Inc. and Esoterix Generic Laboratories, LLC, wholly-owned subsidiaries of Laboratory Corporation of America® Holdings.
BILLING INFORMATION
INTEGRATED ONCOLOGY INTERNAL USE ONLY
… BC/BS
… HMO
… PPO … Indemnity
… Network
… Medicaid
… Medicare … Medical Group/IPA … Hospital/Facility Bill #______________ … Self-Pay
… Billing Information Attached (Please include a copy of insurance card or face sheet.)
Do not attach credit card information to this form.
Insurance Company Name ____________________________________________________
Policy # _____________________________ Group # _____________________________
Relation to Insured:
… Self
… Spouse
… Child
… Other ____________
Patient Signature _________________________________________ Date ________________
© 2014 Laboratory Corporation of America® Holdings. All rights reserved.
By signing this form, I hereby authorize Laboratory Corporation of America® Holdings (LCAH), its subsidiaries and affiliated companies,
to furnish my designated insurance carrier the information on this form if necessary for reimbursement. I also authorize benefits to
be payable to LCAH. I understand that I am responsible for any amounts not paid by insurance for reasons including, but not limited to,
non-covered and non-authorized services. I permit a copy of this authorization to be used in place of the original.
onc-166-V6-0214
1B
Determining Necessity of Advance Beneficiary Notice of Noncoverage (ABN) Completion*
1. Diagnose. Determine your patient’s diagnosis.
2. Document. Write the diagnosis code(s) on the front of this requisition.
3. Verify. Determine if the laboratory test(s) ordered for the patient is subject to the Local Coverage Determination or National Coverage
Determination. This information can be located in the policies published by Medicare Administrative Contractor (MAC), CMS, or the
“Documenting Medical Necessity of Laboratory Services” booklet provided by your LabCorp representative.
4. Review. If the diagnosis code for your patient does not meet the medical necessity requirements set forth by Medicare or the test is
being performed more frequently than Medicare allows, an ABN should be completed.
*An ABN should be completed for all tests that are considered investigational (experimental or for research use) by Medicare.
B2A
How to Complete an Advance Beneficiary Notice of Noncoverage (ABN)
Medicare is very specific in requiring that all of the information included on the ABN must be completed. Additionally, LabCorp requests
that the specimen number or bar code label be included on the form. To be valid, an ABN must:
1.
2.
3.
4.
5.
6.
Be executed on the CMS approved ABN form (CMS-R-131).
Identify the Medicare Part B Beneficiary, using the name as it appears on the patient’s red, white, and blue Medicare card.
Indicate the test(s)/procedure(s) which may be denied within the relevant reason column.
Include an estimated cost for the test(s)/procedures(s) subject to the ABN.
Have “Option 1”,“Option 2”, or “Option 3” designated by the beneficiary.
Be signed and dated by the beneficiary or his/her representative prior to the service being rendered.
Integrated Oncology is a brand used by both Accupath Diagnostic Laboratories, Inc. and Esoterix Genetic Laboratories, LLC, wholly-owned subsidiaries of Laboratory Corporation of America® Holdings.
©2014 copyright Laboratory Corporation of America® Holdings. All rights reserved.
ONC 166-V6-02172014