Get Uf_tec_009 Molecular Request Form - Unistel Medical Laboratories

Filling out the UF_TEC_009 Molecular Request Form is essential for ensuring accurate specimen processing at Unistel Medical Laboratories. This guide provides a clear, step-by-step approach to completing the form online, ensuring all required information is submitted correctly.

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 in the requisition number, ensuring that this unique identifier is clearly noted at the top of the form.
3. Provide patient information, including patient ID number, surname, first name, birth date (in the format mm/dd/yyyy), and address. Ensure that all details are entered accurately.
4. Select a title from the provided options (Mr, Ms, Dr, Prof) and indicate the patient's gender by selecting either Male or Female.
5. Complete the genetic analysis section by ticking off the requested tests. Choose from the provided list, ensuring clarity on each test that is needed.
6. Fill in the contact information for the patient, including home phone and cell phone numbers.
7. Review the certification statement to ensure you understand it, then provide a signature where indicated. This signifies consent for the selected tests and acknowledgment of financial responsibilities.
8. Complete the referring physician or medical facility section. Enter the name of the referring physician, pathology practice, reporting address, and contact information including phone, fax, and email.
9. Fill in the guarantor details, including ID number, surname and initials, address, member number, and medical aid information.
10. Specify the specimen type by selecting from the options provided, detailing if it is bone, blood, amnion, specimen fluid, etc.
11. Indicate the date and time that the specimen was collected, ensuring that these details are accurate.
12. Note specific mutations if applicable, and any other DNA diagnostic tests that may be relevant.
13. If applicable, indicate whether authorization is needed for medical aid claims and provide the authorization number if available.
14. Finally, save the completed form changes, and download, print, or share the document as required.

Complete your document online to ensure accurate processing and avoid delays.