Surgical Pathology Equisition F #432907/15 Form
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1A
C
C
PATIENT ID/ROOM #
SURGICAL ID
COMMENTS
Fasting
Non-Fasting
O
ENTRIES WILL SHOW ON REPORT
U
NAME, LAST (OR CODE NAME) Please Print
FIRST
P
N
A
T
STREET
APT. #
CITY
T
P
I
STATE
ZIP
DATE OF BIRTH
AGE
M/F
COLLECTED
H
AM
E
MO
DAY YR
DATE
TIME
PM
Y
N
PATIENT PHONE NO.
PATIENT CELL
PATIENT EMAIL/FAX
(
)
(
)
S
T
I
RACE/ETHNICITY:
C
NATIVE AMERICAN
ASIAN
AFRICAN-AMERICAN
CAUCASIAN
ASHKENAZI JEWISH
PACIFIC ISLANDER
HISPANIC
OTHER ___________________________
I
BILLING INFORMATION
A
N
BILL TO:
MEDICARE
MEDICAID
INSURANCE CARRIER:
I I
I I
S
INSURANCE
PATIENT
CLIENT
I I
I I
I I
INS. ID #
GROUP #
SUBSCRIBER’S NAME
DATE OF BIRTH
DX CODE
DX CODE
DX CODE
DX CODE
.
.
.
.
__ __ __
__ __
__ __ __
__ __
__ __ __
__ __
__ __ __
__ __
INSURANCE ADDRESS
CITY
STATE
ZIP
REFERRING PHYSICIAN NAME
When ordering tests for Medicare/Medicaid patients, providers should only order tests
SECONDARY INSURANCE CARRIER NAME
INS. ID #
GROUP #
SUBSCRIBER’S NAME
DATE OF BIRTH
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
___________________________________________
P TIENT ST TUS – ONE MUST BE CHECKED
HOSPITAL PATIENT
HOSPITAL INPATIENT
OUTPATIENT
NOT A HOSPITAL PATIENT DATE OF DISCHARGE ______ /______ /______
PHYSICIAN’S SIGNATURE (REQUIRED FOR MEDICAID AND MEDICARE)
ALL INSURANCES
RELATIONSHIP TO SUBSCRIBER:
CHILD
SELF
SPOUSE
OTHER ____________________________________
SURGICAL PATHOLOGY REQUISITION FORM
PLEASE SUBMIT ALL PERTINENT DATA BELOW
# of Samples______________
Check here to digitally image slides
I I
SPECIMEN
COLLECTION
LOCATION
METHOD
CLINICAL DIAGNOSIS: __________________________
Sample A
Surgical/Excision
____________________________________
______________________________________________
Biopsy – If Skin, specify:
Shave
Punch
____________________________________
FNA – Specify Fixative:
CytoLyt
Alcohol
PREVIOUS SURGERY:
YES
NO
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I I
____________________________________
Name _______________________________
Other __________________________________
TYPE: ____________________________________
Sample B
Surgical/Excision
____________________________________
Biopsy – If Skin, specify:
Shave
Punch
____________________________________
DATE: ____________________________________
FNA – Specify Fixative:
CytoLyt
Alcohol
Name _______________________________
____________________________________
Other __________________________________
DIAGNOSIS:_______________________________
Sample C
Surgical/Excision
____________________________________
Biopsy – If Skin, specify:
Shave
Punch
CLINICAL HISTORY:
____________________________________
FNA – Specify Fixative:
CytoLyt
Alcohol
Name _______________________________
____________________________________
Other __________________________________
______________________________________________
Sample D
Surgical/Excision
____________________________________
______________________________________________
Biopsy – If Skin, specify:
Shave
Punch
____________________________________
FNA – Specify Fixative:
CytoLyt
Alcohol
Name _______________________________
____________________________________
Other __________________________________
______________________________________________
Sample E
Surgical/Excision
____________________________________
______________________________________________
Biopsy – If Skin, specify:
Shave
Punch
____________________________________
FNA – Specify Fixative:
CytoLyt
Alcohol
Name _______________________________
____________________________________
Other __________________________________
INTERNAL CONTROL (LAB USE ONLY)
BREAST BIOPSY SAMPLE INFORMATION (CAP/ASCO GUIDELINES)
SLIDES
FRESH TISSUE
BLOCK
Microcalcifications detected by mammogram?
YES
NO
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Fixation Time _________________ Cold Ischemia Time _________________
FORMALIN
OTHER
CAP/ASCO Breast Guidelines: ER/PgR/HER2 Fixation Time: 6-72 hrs in 10% neutral buffered formalin, Cold Ischemia Time: Less than 1 hr.
LEVEL
REPORT __ __ __ __ __
ADDITIONAL TESTS/COMMENTS
LAB I.D. NO.
PLEASE DO NOT WRITE BELOW THIS LINE. FOR LABORATORY USE ONLY.
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FAX RESULT
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SEND COPY
9993-7
9991-1
(
) ______________________
NAME ______________________________________________
A Business Unit of BioReference Laboratories, Inc.
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CALL RESULT
481 EDWARD H. ROSS DRIVE
STREET ____________________________________________
9990-3
ELMWOOD PARK, NJ 07407-0621
(
) ______________________
CITY _________________ STATE_______ ZIP _____________
800-627-1479 tel. • 201-791-8760 fax
Form #4329 (Rev. 07/15)
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