Get Test Requisition Form - Personal Genome

Filling out the TEST REQUISITION FORM - Personal Genome online can streamline the process of submitting essential information for testing. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete your form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information in the designated fields. Provide the last name, first name, medical record number, date of birth, and contact details, including street address, city, state, postal code, and preferred email.
3. Fill in the ordering physician's information. Enter the physician’s name, office or practice name, and their contact details, including phone and fax numbers.
4. Specify the pathology information by indicating the testing type. Choose from options such as CancerSelect 125 tissue test or PlasmaSelect 64 plasma test and specify whether it is for tumor only, whole blood, or other relevant details.
5. In the specimen retrieval section, indicate whether you would like PGDx to contact the pathology department for specimen retrieval or if you will arrange it yourself.
6. Provide the necessary specimen information. Enter the diagnosis, primary tumor site, specimen site, accession ID, stage, ICD codes, collection date, and histology.
7. Complete the billing information section, making sure to check applicable boxes for patient status and insurance details. Input primary and secondary insurance information as well as the insured's details.
8. After ensuring all sections are correctly filled out, review the form for accuracy. The physician's signature is required; ensure this is included along with the date signed.
9. Once all information is entered and confirmed, save any changes made to the form. You can choose to download, print, or share the completed document as needed.

Complete your documentation online today and streamline your testing process.