Forms to Download
Per your office's request, we are sending all the required forms needed to complete a review of your patient's biopsy. We have enclosed the Biopsy Requisition forms, Informed Consent for Treatment and Release of Information forms, Formalin Solution bottles, plastic bags and prepaid return envelopes.
For this to be completed in a timely manner, please make sure to:
Completely fill out and return the Biopsy Requisition form
Submitting Doctor Information
• Doctor's FIRST and LAST name
• Doctor's full address
• Doctor's PHONE and FAX numbers
• Office email address
• Doctor's NPI #
• Patient's FIRST and LAST name
• Patient's full address
• Patient's phone number
• Patient's DATE OF BIRTH
If the patient is under 18 years of age ...
Guardians FIRST and LAST name, DOB (if available)
• Patient's SOCIAL SECURITY#
Please specify whether we should we be billing the Patient, Medicare or the Physician
If the patient has Medicare, please include a copy of their Medicare card
Date of Biopsy, Description of Lesion and Clinical Diagnosis
The patient MUST completely fill out. sign and return "Informed Consent for Treatment and Release of Information" form.
The specimen cannot be processed without this signed form.
Thank you for your attention to this matter. This will help to expedite the processing of your patient's biopsy and the return of the report to your office.