OGY Date: PHS# (To be completed by MGP Lab Staff) Solid Tumor Test Requisition PATIENT IDENTIFICATION Name: Birth Date: Sex: M F Surgical Pathology/Cytology #: SSN/MRN: BILLING INORMATION Person/Institution Responsible for Payment: Billing Address: Phone #: CLINICAL HISTORY Clinical Diagnosis: Diagnostic Question Being Referred: ICD-9 Code(s): SPECIMENS Paraffin Sections FNA Fresh in Preservative Solution CLIENT INFORMATION Requesting Institution: Requesting Physician: Physician Address: Pho.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the UPMC Solid Tumor Test Requisition online
Completing the UPMC Solid Tumor Test Requisition online is a crucial step in the diagnostic process for patients suspected of having solid tumors. This guide provides clear and detailed instructions to assist users in accurately filling out the form to ensure efficient processing and handling of specimens.
Follow the steps to complete the UPMC Solid Tumor Test Requisition online.
- Click ‘Get Form’ button to obtain the UPMC Solid Tumor Test Requisition and open it in the document editor for online completion.
- Fill in the patient identification section, including the name, birth date, and sex of the patient. Ensure that the Surgical Pathology/Cytology number and the SSN/MRN are accurately provided.
- Complete the billing information by providing the name of the person or institution responsible for payment, followed by the billing address and contact phone number.
- Detail the clinical history by entering the clinical diagnosis, the diagnostic question being referred, and the ICD-9 code(s) relevant to the patient.
- In the specimens section, specify the type of samples collected (e.g., paraffin sections, frozen tissue, FNA fresh in preservative solution, etc.) according to the sample available.
- In the client information section, provide the name of the requesting institution and the requesting physician, along with their respective addresses and phone numbers.
- For the solid tumors section, indicate which personalized cancer mutation panels or specific tests are being requested for the patient’s specimen.
- Before finalizing, review all entered information in the form to ensure accuracy and completeness.
- Once all fields are filled and confirmed, you can save changes, download a copy of the filled form, print it for physical submission, or share it as necessary.
Take the next step towards completing your forms online by following these detailed steps.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
The format is "NCT" followed by an 8-digit number (for example, NCT00000419)....
Our clinical focus is on performing and interpreting complex genetic tests in the areas of...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.