Get Requisition Form - Interpace Diagnostics

Completing the REQUISITION FORM - Interpace Diagnostics online is a straightforward process that requires attention to detail. This guide will provide step-by-step instructions to ensure that all necessary information is accurately filled out.

Follow the steps to successfully complete the requisition form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the required patient information, including the patient’s last name, first name, middle initial, date of birth, address, city, state, and zip code. Ensure that all fields marked as 'Required' are completed.
3. Provide information about the ordering physician, including their contact number and account number. If there is a patient’s face sheet, attach it to the test.
4. Complete the billing information section, including the office contact name, NPI number, and delivery method for results (fax or mail). Ensure that patient billing information is attached.
5. Select the test menu option appropriate for the patient. Make sure to indicate if the test is ThyGenX with reflex to ThyraMIR or ThyGenX only.
6. Fill in the specimen and diagnosis information, including date of FNA procedure, specimen type, and ICD codes. It is important to include the appropriate diagnosis codes that are supported by the patient’s medical record.
7. Indicate the location of the FNA procedure and ensure each specimen vial is labeled with two forms of patient identifiable information.
8. Complete the clinical history section, including size of nodules and cytology diagnosis. This information aids in the evaluation of the specimens.
9. Sign and date the form in the authorized signature section to certify the request is medically necessary.
10. Review all information entered for accuracy. Once completed, users can save changes, download, print, or share the form as needed.

Complete your documents online to ensure accuracy and efficiency.