Clinical Pathology Requisition

Purpose:
To aid the client in the completion of a Clinical Pathology Requisition.

Procedure:

1. Enter the patient’s last name, first name and middle initial (see note below if attaching demographic sheet)
2. Enter the patient’s date of birth.
3. Enter the gender of the patient as Male or Female.
4. Enter the patient’s telephone number (if available).
5. Enter the patient’s social security number.
6. Enter the medical record number if the specimen is coming from a hospital.
7. Enter the street address and the city, State and zip code.
8. Enter the requesting physician’s FULL name.
9. Enter the hospital / clinic / or physician’s office name.
10. Enter the collection date and time.
11. Enter the name of the person completing this requisition. This will help if we need to call to verify something unclear on the requisition.
12. 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.
13. Enter any additional physician’s FULL name that would like a copy of the report.
14. If correlation with a previous or concurrent case is requested please check the box to the right and provide the previous accession number if available.
15. Enter the priority and location of the collection. 
16. Enter the Clinical Information section and fill in the remaining areas based on the type of specimen you are collecting.

NOTES:

• Minimum requirement for labeling of specimens and slides is the patient’s FULL name, 2nd identifier (DOB or MR#), and source of specimen if sending a surgical or non-gyn cytology 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.