Follow the steps to complete the request form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. In the 'To:' section, enter the name of the medical facility or recipient to whom the request is addressed.
3. In the 'From:' section, provide your name or the name of the person submitting the request.
4. Fill out the 'Telephone' field with your contact number for follow-up inquiries.
5. Complete the 'FAX' section with the appropriate fax number for submission.
6. Input the 'JPC Accession Number' in the designated field, which is crucial for tracking the request.
7. In the 'Patient Name' field, enter the full name of the patient associated with the request.
8. Fill in the 'Surgical Case #' if applicable, ensuring it corresponds to the patient's case.
9. In the narrative section labeled 'Indication for biopsy or operation,' provide a brief description of why the biopsy was performed.
10. Supply details in the section for 'Basis for patient’s previous diagnosis' to give context to the pathology request.
11. Detail the 'Operative findings' in the field provided, offering insights from any surgical procedures related to the case.
12. Provide any available 'Clinical evidence of liver disease', ensuring it's as thorough as possible.
13. Include the patient's 'History of alcohol use' if relevant, as it can impact liver health assessments.
14. Detail any 'History of hepatitis exposure,' highlighting factors such as transfusions or IV drug use.
15. Summarize the 'History of diabetes or obesity', indicating if these conditions are present.
16. List any 'Medications' the patient has taken, including nonprescription drugs, vitamins, herbal preparations, and dietary supplements, along with their usage dates.
17. If applicable, include any 'Imaging studies or results' relevant to the liver and biliary tract.
18. In the 'Laboratory data & date obtained' section, supply the values for the listed tests (AST, ALT, Alkaline Phosphatase, etc.) as well as the relevant dates.
19. Conclude by checking that all information is accurate, and know that your ‘Other’ notes can capture any additional relevant details.
20. Once completed, save any changes to your form, and consider downloading, printing, or sharing the document as needed.

Begin completing your request form online today to ensure timely processing.