Get Tumor Test Requisition Form - Ambry Genetics

Completing the Tumor Test Requisition Form is an essential step for requesting genetic testing, and it is important to do so accurately to avoid any delays in processing. This guide provides clear, step-by-step instructions tailored to help you successfully fill out the form online.

Follow the steps to fill out the Tumor Test Requisition Form correctly.

1. Click ‘Get Form’ button to obtain the Tumor Test Requisition Form and open it for editing.
2. Provide patient information. Fill in the patient's name, date of birth, date of death (if applicable), phone number or email, and address including city, state, and zip code. Indicate the biological sex and ethnicity from the options provided.
3. Complete the specimen information section. Specify the type of specimen (blood/saliva and tumor tissue) you are submitting, along with the collection date. If phlebotomy services are requested, select the appropriate options and fill in the collection date and time.
4. Fill in the pathology information, ensuring to include the required pathology report for the tumor specimen. Provide the institution name, pathologist's name, and contact information.
5. Complete the ordering licensed provider/sending facility information, including the facility name, address, and contact details of the licensed provider who is ordering the test.
6. Include any additional results recipients if necessary, such as genetic counselors or other medical providers, with their contact details.
7. Confirm informed consent and medical necessity by signing the relevant section. Ensure that all information is true and complete to facilitate processing.
8. Fill out the insurance billing information, indicating the patient's relationship to the policyholder, insurance company details, and the policy number.
9. If applicable, complete the patient payment section, providing details for payment by check or credit card.
10. Once all sections are filled out, review the information for accuracy. Save changes, download or print the completed form, and be prepared to share it as required.

Start completing your Tumor Test Requisition Form online today to ensure a smooth testing process.