Get Test Requisition Form - Biotheranostics
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How to fill out the Test Requisition Form - BioTheranostics online
Filling out the Test Requisition Form - BioTheranostics online is an essential step in ensuring timely and accurate testing of specimens. This guide will provide a clear and structured approach to completing the form effectively.
Follow the steps to complete the Test Requisition Form accurately.
- Click the 'Get Form' button to access the Test Requisition Form and open it for editing.
- In the 'Ordering Physician' section, enter your name, National Provider Identifier (NPI), email, practice name, and hospital or laboratory details, including address, city, state, phone, and fax.
- Proceed to the 'Patient Information' section. Fill in the patient's name, date of birth (DOB), social security number, sex, and address. Also, provide the patient's clinical diagnosis and medical record number.
- In the 'Specimen Information' section, specify the biopsy site, date collected, fixative type, and attach the required ICD-9 codes that may apply.
- Complete the 'Billing Information' section. Check the appropriate box to indicate the patient's hospital status and select who the bill should be sent to, whether it be insurance, the patient, or another facility.
- For the 'Tests Requested' section, select the tests you need, including CancerTYPE ID, PRÉCIS Precision Medicine, and any specific biomarker analyses.
- Sign and date the 'Physician/Practitioner Certification' section to certify that you authorize the processing of the tumor specimen and that the test is medically necessary.
- Once the form is fully completed, review all entries for accuracy. You can then save your changes, download the document, print it, or share it as necessary.
Complete your Test Requisition Form - BioTheranostics online today to ensure efficient processing of your specimen.
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The test requisition combines patient registration information, billing information, specimen information, barcoded specimen labels and a provider order for confirmation of testing.
Fill Test Requisition Form - BioTheranostics
Ship with specimen to Biotheranostics' laboratory OR fax this form to and Biotheranostics will request the specimen from Pathology. Ship completed requisition with specimen to Biotheranostics OR fax this form to and. Biotheranostics will request the specimen from Pathology. Place the specimens, completed Test Requisition, completed Specimen. Request Form, pathology report and supporting documents in a Biotheranostics Specimen. Breast Cancer Index Testing is available in all 50 states. Click here to order a test directly from Breast Cancer Index or request an order form. To submit this form, attach the completed requisition with all required documents, including any pathology reports. Select the appropriate ICD-10-CM code. , a Hologic Company.
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