Get Ucla Health Form 16095 2016-2025

The UCLA Health Form 16095 is a crucial document for submitting molecular oncology requisitions. This guide provides detailed instructions to help users complete the form online with ease and confidence.

Follow the steps to successfully complete the UCLA Health Form 16095.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editing platform.
2. Begin by filling out the patient's name. Enter the last name followed by the first name as required.
3. Input the medical record number and date of birth of the patient in the designated fields.
4. Select the patient's location and mark the sex by checking either 'M' for male or 'F' for female.
5. Provide the ordering physician's name, ensuring to include both last and first names. Also, enter the pager number for communication.
6. If needed, specify whether a copy of the requisition should be sent to another physician by entering their details and pager number.
7. Fill in the specimen information by entering the collection date, collection time, and the name of the person who collected the sample.
8. Enter the appropriate ICD-10 code or diagnosis related to the patient's condition, if relevant.
9. In the next section, choose the options that apply to the type of specimen provided, such as ‘FFPE tissue (unstained slides)’ or ‘FFPE tissue (paraffin block)’.
10. Complete the patient information/history section by indicating the patient's ethnicity, pertinent family history, and any other relevant information.
11. Select any applicable next-generation sequencing options by checking the relevant boxes for lung cancer, colorectal cancer, or thyroid cancer mutation analyses.
12. If applicable, select any single gene tests by checking the relevant boxes under lung, colorectal, and thyroid categories.
13. Finally, ensure you correctly fill in the address and contact information for delivering the samples to the UCLA Molecular Diagnostics Laboratories.
14. Once all fields are complete, you can save changes, download the form, or print it for submission.

Complete your UCLA Health Form 16095 online today to ensure timely processing of your requisition.