Hematopathology Requisition

Purpose:
To aid the client in the completion of a Bone Marrow requisition.

Procedure:

1. The “Hematopathology Requisition should be used by all hospitals or offices that perform bone marrows.
2. Enter the patient’s last name, first name and middle initial (see note below if attaching demographic sheet)
3. Fill out the label(s) at the top of the requisition with the patient’s full name, 2nd identifier (date of birth or MR#), and specimen source. 
4. Enter the patient’s date of birth.
5. Enter the gender of the patient as Male or Female.
6. Enter the patient’s telephone number (if available).
7. Enter the patient’s social security number (if hospital policy allows).
8. Enter the medical record number if the specimen is coming from a hospital.
9. Enter the street address and the city, state and zip code.
10. Enter the requesting physician’s FULL name.
11. Enter the hospital / clinic / or physician’s office name.
12. Enter the collection date and time.
13. Enter the name of the person completing this requisition. This will help if we need to call to verify something unclear on the requisition.
14. Enter the insurance numbers (include the policy number and group number) and the address of the insurance. Please keep in mind that many insurance companies have multiple addresses so in order for us to bill the insurance, we will need the address.  A photocopy of the insurance card is preferred.
15. Enter any additional physician’s FULL name that would like a copy of the report.
16. If correlation with a previous or concurrent biopsy is requested please check the box to the right and provide the previous accession number if available.
17. Enter the priority and location of the collection.
18. Enter the specimen type that you are submitting
19. Enter the Clinical Information section and fill in the remaining areas based on the type of specimen and test requests you are collecting (see more detailed instructions in procedure)
20. Be sure to include CBC results and a peripheral smear with every bone marrow
21. If ordering cytogenetics you must include a completed ARUP Cytogenetics form as well.

NOTES:

• Minimum requirement for labeling of specimens and slides is the patient’s FULL name, 2nd identifier (DOB or MR#), and source of specimen.
• The exact spelling of the patient’s name should agree with the requisition. Any discrepancies will need to be resolved before we will process the specimen.
• Please note that if your office would like to send a demographic sheet along with the requisition, the following needs to be filled in on the requisition: The patient’s full name, the date of birth, the physician’s full name and location, and the collection date and time. The rest of the demographic information, we will take from the demographic sheet.