Get Confirmmdxtestrequisitionform

Filling out the Confirmmdxtestrequisitionform online can seem daunting, but with clear guidance, it becomes a manageable task. This guide will walk you through each section of the form, ensuring that all required information is accurately provided.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the document and open it in your designated editor.
2. Begin with the client information section. You will need to provide the first and last name of the ordering physician, as well as their National Provider Identifier (NPI). Make sure this information is accurate to avoid any delays.
3. Proceed to the molecular diagnostics section where you should check the appropriate box indicating that prostate tissue samples submitted will be analyzed by ConfirmMDx for prostate cancer.
4. In the patient information section, fill in the patient's name (first, middle, last), date of birth, address, phone number, city, state, zip code, and social security number. Ensure that this information reflects the patient's records accurately.
5. For clinical information required for reimbursement, enter the appropriate ICD-9 codes related to the patient’s condition and biopsy history. Include any relevant histopathology findings and dates for the last digital rectal exam (DRE) and PSA test.
6. In the specimen information section, you are asked to provide details about the tissue specimens. Include the collection date, retrieval date from archive, and any additional relevant information such as fixative type and specimen IDs.
7. Fill out the required billing information section, indicating the patient status and providing insurance details as necessary. Include primary and secondary insurance information if applicable.
8. Complete the specimen request by providing the necessary contact information for the department obtaining the specimens and any additional reporting requests.
9. In the authorization section, an authorized signature is required. Do not use stamped signatures; instead, ensure that the individual signing the form is present.
10. Review all sections thoroughly for accuracy before submitting the form. Once everything is complete, you will have the option to save changes, download, print, or share the form as needed.

Complete the Confirmmdxtestrequisitionform online today to ensure timely processing of your request.