Docstoc

Date

Document Sample
Date  Powered By Docstoc
					                                                                7988 W. Marigold Street, Suite 150                                        DERMATOPATHOLOGY REQUISITION
                                                                Boise, ID 83714

                                                                (800) 850-PATH(7284)
                                                                (800) 838-5913 Fax                                                           Date:                /                   /
CLIENT INFORMATION                                                                                     PATIENT INFORMATION
                                                                                                       LAST NAME                                         FIRST NAME                               M.I.

                                                                                                       STREET ADDRESS                                                                     APT #

                                                                                                       CITY                                              STATE                   ZIP CODE

                                                                                                       PATIENT PHONE NUMBER                              PATIENT SS#

                                                                                                       GENDER        M/F            DATE OF BIRTH                                         AGE

                                                                                                                              OR ATTACH PATIENT INFORMATION HERE

BILLING INFORMATION - Primary Insurance                                                                BILLING INFORMATION - Secondary Insurance
or attach a copy of insurance card - both sides                                                        or attach a copy of insurance card - both sides
SUBSCRIBER NAME / RELATIONSHIP TO INSURED  SELF          SPOUSE     CHILD                           SUBSCRIBER NAME / RELATIONSHIP TO INSURED  SELF       SPOUSE        CHILD


SUBSCRIBER BIRTH DATE                                                                                  SUBSCRIBER BIRTH DATE

COMPANY NAME                                                                                           COMPANY NAME

ADDRESS                                                                                                ADDRESS

CITY                                                 STATE                  ZIP CODE                   CITY                                              STATE                    ZIP CODE

EMPLOYER NAME                                                                                          EMPLOYER NAME

GROUP/CONTRACT #                                     MEMBER ID #                                       GROUP/CONTRACT #                                  MEMBER ID #

MEDICARE #                                           MEDICAID ID #                                     MEDICARE #                                        MEDICAID ID #



PATIENT INFORMATION
INDICATE SITE OF EACH BIOPSY                            CHECK FOR
                                              TYPE                    CLINICAL INFORMATION
  ON ILLUSTRATION BELOW                                 MARGINS?




A
                                       O SHAVE
                                       O PUNCH
                                                             YES
                                       O EXCISION
                                       O OTHER
                                                             NO




B
                                       O SHAVE
                                       O PUNCH
                                                             YES
                                       O EXCISION
                                       O OTHER
                                                             NO




C
                                       O SHAVE
                                       O PUNCH
                                                             YES
                                       O EXCISION
                                       O OTHER
                                                             NO

PHYSICIAN’S SIGNATURE____________________________________________________________________ DATE ______________________________

                                                                                                                                                                            FOR LAB USE ONLY
                                                                                                                                                                       CPT Codes:               ICD-10
                                                                                                                                                                                                Codes:

                                                                                                                                                                       A.


                                                                                                                                                                       B.


                                                                                                                                                                       C.




                                                                               White Copy: Lab • Yellow Copy: Doctors O ce

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:18
posted:5/8/2011
language:English
pages:1