All the required forms (listed below) will be needed to complete a review of your patient's biopsy.
In order 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
• 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
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.
* Please inform your patients that there will be an ADDITIONAL FEE for tissue reading.
** Our office only accepts (State Issued) Medicare.
*** WE DO NOT ACCEPT ANY OTHER INSURANCE. The patient can submit their bill to their insurance company for reimbursement.
Forms to Download
Oral Pathology Patient Form
Oral Pathology Informed Consent
Oral Pathology Mailing Label