Get Anatomic Pathology Request Form

O. B. CHECK MARGINS DATE OBTAINED DATE OF ACCIDENT IF NO FAULT/WORKERS COMP CONSULTATION POLICY CALL MD W/RESULTS PT RELATIONSHIP TO INSURED HISTOPATHOLOGY TEST REQUEST INCLUDES SPECIAL BILLABLE STAINS DETERMINED BY PATHOLOGIST PHYSICIAN MUST BE CONTACTED PRIOR TO PERFORMANCE OF SPECIAL BILLABLE STAINS BIOPSY OF SPECIMEN BOTTLES EXCISION BIOPSY SITE FNA DURATION / HISTORY / DESCRIBE SPOUSE Perform Cytospin if necessary NAME OF INSURANCE CO. INSURANCE ADDRESS If previous biopsy on file with Acupath and same insurance please check box SECONDARY INSURANCE A B SELF CHILD SAMPLE GROUP NAME/ C REFERRAL CLINICAL DIAGNOSIS SOURCE SEE ANATOMIC SITE DIAGRAMS AT BOTTOM OF FORM PREVIOUS BIOPSY D ADDRESS HPV TISSUE ISH If Screen do Subtype 6/11 16/18 31/33 NON-GYNECOLOGIC CYTOLOGY TEST REQUEST Breast Cytology Urine Cytology NIPPLE DISCHARGE FLUID R L VOIDED URINE HALO BREAST TEST NAF POST CYSTOSCOPY FINE NEEDLE ASPIRATION FNA I authorize the release to my insurance carrier of any medical information necessary to process this claim and I authorize payment of medical benefits directly to Acupath Laboratories Inc. I understand that if I do not have insurance I will be billed directly by Acupath Laboratories Inc. I also authorize release of my pathology results to my doctor utilizing all methods of transmission according to HIPAA regulations. TEL 1-888- ACUPATH 228-7284 GYNECOLOGIC PATHOLOGY / TEL 516 775-8103 REQUEST FORM FAX 516 326-3452 28 S* TERMINAL DRIVE PLAINVIEW NY 11803 GY003L WWW*ACUPATH. COM CYTOLOGY ANY OMISSION MAY RESULT IN DELAY OF REPORT FOR THE ABSOLUTE HIGHEST STANDARD IN GYNECOLOGIC PATHOLOGY 2010 PATIENT INFORMATION RACE optional M F SS DATE OF BIRTH LAST NAME FIRST NAME M. I. STREET ADDRESS PHYSICIAN SIGNATURE CITY DUPLICATE REPORT TO STATE TEL* ZIP CHART PATH PATIENT S PRIMARY INSURANCE BILL TO COMMENTS TO PRINT OUT ON REPORT MEDICARE PATIENT OTHER NO FAULT INSURED S NAME WORKERS COMP D. O. B. CHECK MARGINS DATE OBTAINED DATE OF ACCIDENT IF NO FAULT/WORKERS COMP CONSULTATION POLICY CALL MD W/RESULTS PT RELATIONSHIP TO INSURED HISTOPATHOLOGY TEST REQUEST INCLUDES SPECIAL BILLABLE STAINS DETERMINED BY PATHOLOGIST PHYSICIAN MUST BE CONTACTED PRIOR TO PERFORMANCE OF SPECIAL BILLABLE STAINS BIOPSY OF SPECIMEN BOTTLES EXCISION BIOPSY SITE FNA DURATION / HISTORY / DESCRIBE SPOUSE Perform Cytospin if necessary NAME OF INSURANCE CO. INSURANCE ADDRESS If previous biopsy on file with Acupath and same insurance please check box SECONDARY INSURANCE A B SELF CHILD SAMPLE GROUP NAME/ C REFERRAL CLINICAL DIAGNOSIS SOURCE SEE ANATOMIC SITE DIAGRAMS AT BOTTOM OF FORM PREVIOUS BIOPSY D ADDRESS HPV TISSUE ISH If Screen do Subtype 6/11 16/18 31/33 NON-GYNECOLOGIC CYTOLOGY TEST REQUEST Breast Cytology Urine Cytology NIPPLE DISCHARGE FLUID R L VOIDED URINE HALO BREAST TEST NAF POST CYSTOSCOPY FINE NEEDLE ASPIRATION FNA I authorize the release to my insurance carrier of any medical information necessary to process this claim and I authorize payment of medical benefits directly to Acupath Laboratories Inc* I understand that if I do not have insurance I will be billed directly by Acupath Laboratories Inc* I also authorize release of my pathology results to my doctor utilizing all methods of transmission according to HIPAA regulations.