Follow the steps to complete the Requisition Form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, provide the ordering physician's information including their name, address, telephone number, and institution or practice name.
3. Complete Section II with the patient's information including their name, date of birth, gender, social security number, medical record number, address, phone number, and email.
4. In Section III, provide billing information such as the primary insurance company name, submitting diagnosis, ICD-9 code, method of payment, and whether there is secondary insurance. If applicable, attach a copy of the front and back of the insurance card.
5. Section IV requires the ordering physician's signature along with the date and printed name.
6. In Section V, include details for the treating physician and choose the preferred method of report delivery. If the address is the same as the ordering physician, check the corresponding box.
7. Section VI should include the name and address of the laboratory where the tumor tissue is maintained. At a minimum, the laboratory name and city should be provided.
8. Once all sections are completed, save your changes and proceed to either download, print, or share the form as necessary.

Complete the Requisition Form online today for a streamlined experience.