Get Requisition Form Prenatal & Miscarriage Analysis - Combimatrix

Completing the requisition form for prenatal and miscarriage analysis at CombiMatrix is an essential step in initiating your testing process. This guide provides you with clear and supportive instructions to ensure that each section of the form is filled out accurately and efficiently.

Follow the steps to successfully complete the requisition form.

1. Click the 'Get Form' button to access the requisition form and open it for online submission.
2. Begin by filling out the client information section, including the collection date, number of tubes, and specimen ID(s). Choose the sample type from the provided options such as fresh tissue, FFPE block, or cultured amniocytes.
3. Document the pregnancy history accurately, specifying Gravida, Para, and any spontaneous or therapeutic abortions. Indicate the number of fetuses and gestational age.
4. Select the fetal gender and karyotype options that apply. If the karyotype is pending or abnormal, ensure to check those as well.
5. Complete the referring physician information, including their name and NPI, as well as details for the genetic counselor or clinical contact.
6. In the miscarriage analysis indications section, indicate the reason for testing by checking the relevant boxes and providing any additional ICD-9 codes or descriptions.
7. Fill out patient information including last name, first name, collection date, street address, and ensure you include specimen ID(s).
8. Provide details about the patient's pregnancy history, including the current status and number of fetuses again. Specify the gestational age, fetal gender, and karyotype selections.
9. Complete the billing information, indicating whether the account should be billed to personal insurance, Medicare, or Medicaid. Fill out the insured information accurately with the necessary details.
10. Read and complete the patient authorization/assignment section, providing a printed name and signature of the patient or guardian.
11. If applicable, check any additional options for prenatal or ancillary studies. Include any special instructions regarding fetal anomalies for better interpretation of results.
12. Finally, save your changes, download a copy, print the form, or share it as needed to ensure your complete application is submitted.

Complete your requisition form online today to ensure timely processing of your prenatal or miscarriage analysis.