Gi Pathology Requisition - F#14146 12/15 Form
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1
2A
C
C
O
PATIENT ID
SURGICAL ID
COMMENTS
■ Fasting ■ Non-Fasting
U
ENTRIES WILL SHOW ON REPORT
N
NAME, LAST (OR CODE NAME) Please Print
FIRST
P
T
A
STREET
APT. # CITY
T
P
I
STATE
ZIP
DATE OF BIRTH
AGE
M/F
COLLECTED
H
AM
MO
DAY YR
E
DATE
TIME
PM
Y
PATIENT PHONE NO.
PATIENT CELL
PATIENT EMAIL/FAX
N
(
)
(
)
S
T
I
RACE/ETHNICITY:
C
NATIVE AMERICAN
ASIAN
CAUCASIAN
■
■
■ AFRICIAN-AMERICAN
■
■ ASHKENAZI JEWISH
I
■ PACIFIC ISLANDER ■ HISPANIC ■ OTHER: ______________________________________________
A
BILLING INFORMATION
N
MEDICARE
MEDICAID
BILL TO:
INSURANCE CARRIER:
S
■
■
INSURANCE
PATIENT
CLIENT
■
■
■
INS. ID # GROUP #
SUBSCRIBERʼS NAME
DATE OF BIRTH
DX CODE
DX CODE
DX CODE
DX CODE
.
.
.
.
__ __ __
__ __
__ __ __
__ __
__ __ __
__ __
__ __ __
__ __
INSURANCE ADDRESS
CITY
STATE
ZIP
REFERRING PHYSICIAN NAME
SECONDARY INSURANCE CARRIER NAME INS. ID # GROUP # SUBSCRIBERʼS NAME
DATE OF BIRTH
When ordering tests for Medicare/Medicaid patients, providers should only order tests that are
medically necessary for the diagnosis or treatment of a patient, generally not for screening.
Only a few screening tests are allowed for certain conditions at specific intervals.
INSURANCE ADDRESS
CITY
STATE
ZIP
PATIENT STATUS – ONE MUST BE CHECKED
ALL INSURANCES
RELATIONSHIP TO SUBSCRIBER
HOSPITAL INPATIENT OUTPATIENT NOT A HOSPITAL PATIENT
___________________________________________
CHILD SELF SPOUSE OTHER _______________
Technical Component Only
With Interpretation
PHYSICIANʼS SIGNATURE (REQUIRED FOR MEDICAID)
CLINICAL HISTORY AND DIAGNOSIS -
Please attach endoscopy report.
ENDOSCOPIC CODES
Please write the applicable number(s) for each corresponding biopsy specimen in the next section below.
DO NOT CIRCLE CODE NUMBERS.
1 EROSION
4 MASS
7 POLYP
10 STRICTURE
12 BARRETTʼS MUCOSA
2 ERYTHEMA
5 NODULARITY
8 POLYPOSIS
11 ULCER
13 OTHER
3 GRANULARITY
6 NORMAL
9 PSEUDOMEMBRANE
BIOPSY DATA
LABELS
TYPE
ESOPHAGUS
STOMACH/
COLON/ILEUM
ENDOSCOPIC CODE/DIAGNOSIS
(Check only one)
(Check only one)
DUODENUM
Ileum
Sample A
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Sigmoid
Fundus/Body
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
_________. _________
____________cm
Duodenum
Transverse
Ileum
Sample B
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Sigmoid
Fundus/Body
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
_________. _________
____________cm
Duodenum
Transverse
Ileum
Sample C
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Sigmoid
Fundus/Body
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
Duodenum
_________. _________
____________cm
Transverse
Ileum
Sample D
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Sigmoid
Fundus/Body
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
_________. _________
____________cm
Duodenum
Transverse
Ileum
Sample E
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Sigmoid
Fundus/Body
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
Duodenum
_________. _________
____________cm
Transverse
Ileum
Sample F
GE Junction
Cardia Antrum
Descending
Biopsy
Cytology
Cecum
From GE Junction
Fundus/Body
Sigmoid
Ascending
Polyp
Polypectomy
Name ____________________
Rectum
Duodenum
_________. _________
____________cm
Transverse
IMMUNOHISTOCHEMISTRY
TUMOR GENETICS
With Interp
Tech Only
Tumor genetic testing is performed off of formalin fixed paraffin embedded tissue (FFPE).
5175-5
N/A
GIST Profile by IHC
OnkoSight Panels - Next Generation Sequencing (See panel components on reverse side)
A972-2
B269-2
HER2 by IHC in Gastric/Gastroesophageal Carcinoma
B821-0
Solid Tumor NGS Panel
A943-3
A944-1
Mismatch Repair Protein for Lynch Syndrome by IHC
B822-8
Colorectal NGS Panel
J158-7
J159-5
H. pylori
OnkoSight Single Gene - Next Generation Sequencing
FISH
J022-5
EGFR
J020-9
C-KIT
With Interp
Tech Only
J024-1
KRAS
J021-7
BRAF
A427-7
A428-5
HER2 by FISH in Gastric/Gastroesophageal Carcinoma
J023-3
NRAS
J045-6
PDGFRA
CYTOLOGY
Single Gene PCR
5244-9
ThinPrep Non-Gyn (CytoLyt
)
®
3371-2
Microsatellite Instability (MSI)
A313-9
MLH1 Hypermethylation
(for MSI-H tumors)
5245-6
Alcohol
NGS/FISH Panels and Reflex Options
J104-1
KRAS by NGS, if negative –> BRAF by NGS
J107-4
BRAF by NGS, if negative –> MLH1 Hypermethylation
H580-4
KRAS by NGS and MSI, if positive –> BRAF by NGS and MLH1 Hypermethylation
H578-8
c-KIT and PDGFRA by NGS
INTERNAL CONTROL (LAB USE ONLY)
SLIDES
FRESH TISSUE
OTHER
BLOCK
FORMALIN
LAB I.D. NO.
■ FAX RESULT
SEND COPY
■
9993-7
9991-1
(
) ______________________
NAME _____________________________________________
CALL RESULT
■
STREET ___________________________________________
487 EDWARD H. ROSS DR.
9990-3
ELMWOOD PARK, NJ 07407-0621
(
) ______________________
CITY ________________ STATE_______ ZIP _____________
Form #14146-2015/12
1-800-627-1479 • Fax 201-791-8760
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