Get Tempus Requisition Form 2019

The Tempus Requisition Form is essential for ordering genomic tests that provide insights into cancer management. This guide offers a clear, step-by-step approach to help users complete the form online with ease and confidence.

Follow the steps to fill out the Tempus Requisition Form online accurately.

1. Click ‘Get Form’ button to access the Tempus Requisition Form and open it in the editor.
2. Begin by filling out the patient information section, which includes fields for the patient's last name, first name, date of birth, medical record number, sex, race/ethnicity, street address, city, state, postal code, country, and phone number.
3. Proceed to the ordering physician information. Enter the ordering physician's last name, first name, email address for report delivery, office/practice/institution name, street address, city, state, postal code, and primary phone number.
4. In the xT panel test options section, select the appropriate test type, indicating whether it involves solid tumors, hematologic malignancies, genomic sequencing, IHC options, or specific sample types.
5. Fill out the pathology information if the pathology report is not attached, including the pathology lab name, tumor specimen collection details, and case number.
6. Complete the billing information section with the diagnosis, ICD-10 primary diagnosis code, date of diagnosis, and insurance details.
7. Sign the physician signature section, certifying that you have explained the purpose and risks of the test to the patient.
8. If necessary, indicate whether the pathology lab is part of the treatment team in the pathology release section.
9. Complete additional clinical information as required, such as cancer type, treatment history, and medications.
10. Finally, review all entered information for accuracy, then save changes, download the form, or share it as needed.

Complete the Tempus Requisition Form online today for efficient processing of your genomic tests.