Get Brigham And Women's Hospital Patient Slide Consultation Request Form

Completing the Brigham And Women's Hospital Patient Slide Consultation Request Form online is a straightforward process. This guide will walk you through each section of the form to ensure you provide all necessary information accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Provide the patient’s full name, gender, and date of birth. Make sure to circle the appropriate gender option. Include the site of the biopsy, for example, 'Right lower leg'.
3. Next, complete the section regarding where the results should be sent. Fill in the name, address, phone number, fax, and email of the individual who should receive the results.
4. If additional copies are needed, please specify in the designated section by providing the relevant details.
5. Proceed to the insurance/billing information section. Input the patient’s address, phone number, insurance provider, policy or group number, and the subscriber's name along with their date of birth. Attach any necessary insurance documentation.
6. Review all provided information for accuracy. Once verified, save any changes made, and prepare to submit the form.
7. Finally, download, print, or share the completed form as needed, ensuring it is sent along with necessary slides, pathology reports, and a billing guarantor form.

Start filling out the required documents online to ensure a smooth consultation request process.