Get Perthera Order Form

Completing the Perthera Order Form online is a straightforward process designed to streamline the ordering of molecular profiling tests. This guide will walk you through the essential steps to ensure your form is filled out accurately and efficiently.

Follow the steps to complete the Perthera Order Form online

1. Press the ‘Get Form’ button to access the Perthera Order Form and open it in your editing tool.
2. Begin by entering the patient's last name and first name in the designated fields.
3. Provide the patient's Social Security Number (SSN) and Medical Record Number (if applicable) to help with identification.
4. Fill in the Office, Practice, or Institution Name where the patient is receiving care.
5. Complete the patient's middle initial (MI) and date of birth for accurate records.
6. Select the patient's gender by marking the appropriate option: Male or Female.
7. Enter the patient’s address, including Address 1, Address 2 (if necessary), city, state, postal code, and country.
8. Provide your Primary and Secondary Phone numbers, along with the Fax number, so you can be contacted easily.
9. In the 'Physician to be Copied' section, enter the name and contact information of the physician for reference.
10. Fill in the 'Procedure Information' section, detailing the hospital or institution's name, procedure location, date, and time.
11. Identify the physician performing the procedure and provide the primary tumor site and the stage of disease.
12. In the 'Patient Insurance Information' section, include the insurance company name, primary cardholder’s name, ID number, and the insurance company's phone number.
13. Indicate the specimen site and whether you grant permission to exhaust a tissue sample by selecting 'Yes' or 'No'.
14. Check the box to provide permission to order molecular profiling for the patient on behalf of the physician.
15. Have the ordering physician sign and date the form to certify the necessity and consent for results release.
16. Once completed, make sure to save any changes made to the form, and choose to download, print, or share as needed.

Get started on completing the Perthera Order Form online now!