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Get UW Medicine Pathology Service Request 2014

1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 Fax: 206-598-8049 UWPathology.org For UW Pathology use MRN: Clear Form Send Reports to MI Sex DOB SSN Patient Address City State Patient Phone # Zip Outside Facility Patient ID # Institution Name Institution Address City State Zip Person Completing Form Phone Fax Requesting Physician (primary): Phone Fax NPI # Referring Physician/Surgeon: Phone Fax NPI # Referring Pathologist: Phone Fax N.

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