REQUISITION FORM INTERPACE DIAGNOSTICS 2515 LIBERTY AVENUE PITTSBURGH, PA 15222 Phone: 844-405-9655 • Email: [email protected] • Fax: 888.674.6894 • www.interpacediagnostics.com PATIENT INFORMATION (Required) ORDERING PHYSICIAN (Required) ACCOUNT # PATIENT’S FACE SHEET ATTACHED TO THE TEST OFFICE/HOSPITAL LAST NAME ADDRESS 1 FIRST NAME MIDDLE INITIAL DATE OF BIRTH (MM/DD/YYYY) ADDRESS 2 CITY, STATE, ZIP STREET ADDRESS PHONE CITY NAME STATE PHONE # MR # EMAIL OFFICE CONTACT PRIMARY INSURANCE ... MEDICARE PATIENT STATUS .......... HOSPITAL INPATIENT HOSPITAL OUTPATIENT RELATIONSHIP TO ........ POLICY HOLDER SELF CHILD RESULTS DELIVERY FAX MAIL MALE ZIP BILLING INFORMATION (Required) NPI # FEMALE SEX INSURANCE SPOUSE BILL PATIENT BILL CLIENT PRIVATE PRACTICE ASC OTHER REFERRAL # ATTACH A COPY OF FRONT AND BACK OF PATIENT INSURANCE CARD AND COMPLETE. INSURANCE NAME SENDING PHYSICIAN (if different from above) POLICY # NAME GROUP # POLICY HOLDER NAME OFFICE / HOSPITAL NAME DATE OF BIRTH (MM/DD/YYYY) STREET ADDRESS STREET ADDRESS CITY CITY STATE PHONE # FAX # ZIP STATE ZIP PHONE # TO BILL SECONDARY INSURANCE, ATTACH A COPY OF FRONT AND BACK OF THE SECONDARY INSURANCE CARD AND COMPLETE. TEST MENU (Required) SECONDARY INSURANCE NAME POLICY # MUST SELECT TEST OPTION GROUP # ICD -9 CODES (Required) ThyGenX with reflex to ThyraMIR - Reflex occurs if mutation is negative or not fully indicative of malignancy - Combined testing informs both benign and malignant nodules ThyGenX only ICD-9 CODES Possible codes for your consideration are listed below. (Fill in above; please do not circle): 226 Suspect benign thyroid 239.7 Thyroid neoplasm, unspecified 241.0 Goiter, uninodular (nontoxic) 241.1 Goiter, multinodular (nontoxic) Other: This listing is not exhaustive; please refer to the ICD Manual for a complete listing. The diagnosis code chosen should always be based upon what can be supported within the patient’s medical record. Testing cannot be done unless ICD-9 code(s) are included. FNA SPECIMEN & DIAGNOSIS INFORMATION SPECIMEN TYPE SPECIMEN LABEL (Required) FNA IN RNA RETAIN ®* • A label must be on each specimen vial with 2 forms of patient identifiable information DATE OF FNA PROCEDURE (sample collection) DATE SENT TO CLINICAL LABORATORY • Indicate the location of the patient’s nodule by marking the image on the right. CLINICAL HISTORY • For multiple nodules, please use additional requisition forms. SIZE OF NODULE(S) (A and B, if applicable) CYTOLOGY DIAGNOSIS (Bethesda Category) Description (optional) BENIGN † (II) ATYPICAL/FLUS (III) SUSPICIOUS FOR NEOPLASM (Hurthle or follicular) (IV) SUSPICIOUS FOR CANCER (V) MALIGNANT (VI) OTHER, PLEASE SPECIFY INSUFFICIENT FOR DIAGNOSIS (I) † Requires additional medical necessity information, such as suspicious ultrasound findings. Please check this box to indicate that additional information is attached. *RNARetain ® is a registered trademark of Asuragen, Inc. ISTHMUS UPPER MIDDLE LOWER RIGHT LEFT AUTHORIZED SIGNATURE (Required) I hereby certify that the request for the above test for which reimbursement from Medicare, or third-party payors, will be sought is reasonable and medically necessary for the diagnosis, care, and treatment of this patient’s condition. I also authorize providing this patient’s test results to the patient’s third-party payor. I certify that the patient or referring physician has given consent to the test I have ordered. MD/DO SIGNATURE THY-GEN-0001-01 (04/15) PRINT NAME ORDER DATE / /