Get Ipi-consultation-request-form-new.doc - Inova

This guide provides clear and detailed instructions for completing the IPI-Consultation-Request-form-new.doc, ensuring that users can easily and effectively submit their consultation requests. By following these steps, you will be able to submit accurate information to the Inova Pathology Institute.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Provide the patient information in the required fields. Start with the patient last name, followed by the first name and middle initial, if applicable. Ensure that all required fields (marked with an asterisk) are completed accurately.
3. Enter the patient’s street address, city, state, and zip code. It is important to provide an exact address to facilitate communication regarding the consultation.
4. Fill in the patient's phone number for contact purposes. Ensure that this number is current and accessible.
5. Complete the date of birth section in the format MM/DD/YY, followed by marking the sex of the patient as M or F.
6. Provide the patient's Social Security number in the specified format. This information is critical for identity verification.
7. In the billing section, indicate the primary insurance details by entering the insurance carrier name, policy number, group or enrollment code, and address. If there is secondary or third-party insurance coverage, include that information as well.
8. Identify the contributor, which is typically the person submitting the form. Include their name, signature, and date. Make sure to provide the contributor’s address and indicate any fax number for sending results.
9. Detail the contributor’s working diagnosis or differential diagnosis, including the appropriate ICD-9 code(s) if available.
10. List any materials that have been forwarded as part of the consultation request, such as surgical path reports or clinical information.
11. Provide the case identification, including the specific biopsy site and the contributor’s accession number.
12. Enter the clinical history by including relevant information such as location, size, duration, symptoms, and any treatment details.
13. Add any additional comments or special requests in the designated section to ensure clarity and comprehensiveness.
14. Once all sections are completed, review the form to ensure all information is accurate and complete. You can then save changes, download a copy, print it, or share the form as needed.

Complete your consultation request online today to ensure timely processing.