Authorization Cover Letter Template (Page 6 of 8) in pdf

Authorization Cover Letter Template Page 6

PPENDIX

(NLST)

ATIONAL

UNG

CREENING

RIAL

- R

ATHOLOGY

PECIMEN

OLLECTION

EQUEST

ORM

Participant Name:

Date of Birth:

Medical Record #:

The NLST participant listed above reported resection of a lung cancer at your institution. We are requesting that you provide us with buffered formalin-fixed paraffin blocks of the

tissue types listed below. For each block, please record the date of procedure, explicit block identification, and provide any additional comments as appropriate.

If no specimens will be sent, please indicate the reason below and fax to << Site FAX >>.

[ ] NO specimens shipped Reason________________________________________________________________________________________

Procedure Date

Tissue Type

Unique Block Identification

Comments about Block

Primary Lung Tumor

histology and grade

Primary Lung Tumor

histology or grade

Normal Lung Tissue

Metastatic Lymph Nodes

Resected Metastases

Non-tumor involved

proximal bronchus

Non-tumor involved

distal bronchioles

1. How soon does material need to be returned to your facility (check box)?

Permanent retention is permitted.

Return in _____ months (3 months minimum required).

2. Please ship this form and the requested specimen(s) using the enclosed pre-paid packaging. OR, if no specimen can be sent, please indicate reason above

and fax this form to:

<<NLST Site Fax #, Attn: << NLST Site Coordinator>>).

<<Name of NLST Site>>

<<NLST Site Street Address>>

<<City, State, Zip code>>

This report contains data protected by HIPAA. Distribute only to authorized staff, and store and dispose in a proper manner.

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