REQUISITION FORM - Interpace Diagnostics

REQUISITION FORM
INTERPACE DIAGNOSTICS
2515 LIBERTY AVENUE
PITTSBURGH, PA 15222
Phone: 844-405-9655 • Email: labsupport@interpacediagnostics.com • Fax: 888.674.6894 • www.interpacediagnostics.com
PATIENT INFORMATION (Required)
ORDERING PHYSICIAN (Required)
ACCOUNT #
PATIENT’S FACE SHEET ATTACHED TO THE TEST
OFFICE/HOSPITAL
LAST NAME
ADDRESS 1
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH (MM/DD/YYYY)
ADDRESS 2
CITY, STATE, ZIP
STREET ADDRESS
PHONE
CITY
NAME
STATE
PHONE #
MR #
EMAIL
OFFICE CONTACT
PRIMARY INSURANCE ...
MEDICARE
PATIENT STATUS ..........
HOSPITAL INPATIENT
HOSPITAL OUTPATIENT
RELATIONSHIP TO ........
POLICY HOLDER
SELF
CHILD
RESULTS DELIVERY
FAX
MAIL
MALE
ZIP
BILLING INFORMATION (Required)
NPI #
FEMALE
SEX
INSURANCE
SPOUSE
BILL PATIENT
BILL CLIENT
PRIVATE PRACTICE
ASC
OTHER REFERRAL #
ATTACH A COPY OF FRONT AND BACK OF PATIENT INSURANCE CARD AND COMPLETE.
INSURANCE NAME
SENDING PHYSICIAN (if different from above)
POLICY #
NAME
GROUP #
POLICY HOLDER NAME
OFFICE / HOSPITAL NAME
DATE OF BIRTH (MM/DD/YYYY)
STREET ADDRESS
STREET ADDRESS
CITY
CITY
STATE
PHONE #
FAX #
ZIP
STATE
ZIP
PHONE #
TO BILL SECONDARY INSURANCE, ATTACH A COPY OF FRONT AND BACK OF THE SECONDARY INSURANCE CARD AND COMPLETE.
TEST MENU (Required)
SECONDARY INSURANCE NAME
POLICY #
MUST SELECT TEST OPTION
GROUP #
ICD -9 CODES (Required)
ThyGenX with reflex to ThyraMIR
- Reflex occurs if mutation is negative or not fully indicative of malignancy
- Combined testing informs both benign and malignant nodules
ThyGenX only
ICD-9 CODES
Possible codes for your consideration are listed below. (Fill in above; please do not circle):
226 Suspect benign thyroid
239.7 Thyroid neoplasm, unspecified
241.0 Goiter, uninodular (nontoxic)
241.1 Goiter, multinodular (nontoxic)
Other: This listing is not exhaustive; please refer to the ICD Manual for a complete listing.
The diagnosis code chosen should always be based upon what can be supported within
the patient’s medical record. Testing cannot be done unless ICD-9 code(s) are included.
FNA SPECIMEN & DIAGNOSIS INFORMATION
SPECIMEN TYPE
SPECIMEN LABEL (Required)
FNA IN RNA RETAIN ®*
• A label must be on each specimen vial with 2
forms of patient identifiable information
DATE OF FNA PROCEDURE (sample collection)
DATE SENT TO CLINICAL LABORATORY
• Indicate the location of the patient’s nodule
by marking the image on the right.
CLINICAL HISTORY
• For multiple nodules, please use additional
requisition forms.
SIZE OF NODULE(S) (A and B, if applicable)
CYTOLOGY DIAGNOSIS (Bethesda Category)
Description (optional)
BENIGN † (II)
ATYPICAL/FLUS (III)
SUSPICIOUS FOR NEOPLASM (Hurthle or follicular) (IV)
SUSPICIOUS FOR CANCER (V)
MALIGNANT (VI)
OTHER, PLEASE SPECIFY
INSUFFICIENT FOR DIAGNOSIS (I)
†
Requires additional medical necessity information,
such as suspicious ultrasound findings. Please check this
box to indicate that additional information is attached.
*RNARetain ® is a registered trademark of Asuragen, Inc.
ISTHMUS
UPPER
MIDDLE
LOWER
RIGHT
LEFT
AUTHORIZED SIGNATURE (Required)
I hereby certify that the request for the above test for which reimbursement from Medicare, or
third-party payors, will be sought is reasonable and medically necessary for the diagnosis, care,
and treatment of this patient’s condition. I also authorize providing this patient’s test results to
the patient’s third-party payor. I certify that the patient or referring physician has given consent
to the test I have ordered.
MD/DO SIGNATURE
THY-GEN-0001-01 (04/15)
PRINT NAME
ORDER DATE
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