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We recognize that the new forms are time-consuming, but by filling them out completely, you will help us help your patient faster.
Please call Lamar Jones at (336) 716-2644 if you have questions about the forms, or to request forms by mail, or click here to Email your request.
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Using the Forms on Your Computer |
| Open the Form |
To open the forms on your computer, you must be connected to the internet, unless you have already saved it to your PC (see below). Choose the form you want to use. Cytopathology and Surgical Pathology • Dermatopathology • Renal Biopsy Request Form |
| Save a Copy |
First type in your contact information in the top right section of the page, and then scroll down to the bottom of the page. Click on the green button that says 'SAVE.' Your computer will use the 'save as' function and ask you where to save it. Click 'OK' or hit enter when you are ready. Be sure to remember where you saved it, and what you called it. |
| Complete it Onscreen |
Put your cursor in the first field and type the information, then hit the 'tab' key or use your mouse to advance to the next field. Use the enter key or a mouse click to place a check mark in boxes when appropriate. The 'marital status' and 'race' fields have drop-down boxes to select categories that correspond to our billing system codes. (Category details are below if you are filling the forms in manually.) |
| Print a Form |
Click on the 'PRINT' button at the bottom of the page. The print menu that will come up has a blank on the right side, near the middle, that allows you to say how many copies you want to print. We recommend that you don't change any of the other settings. |
| Clear the Form |
To delete everything you have typed in the form and start over, click the green 'CLEAR' button at the bottom of the page. |
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A Few Things Before You Start |
| Inaccurate or incomplete information on the form causes specimen processing delays, billing delays, and generally increases turnaround times. |
| The form itself is a doctor's order and therefore a legal document that will be a permanent part of the patient's record. |
| As with any physician orders, all request forms must be signed by a physician (or physician equivalent). |
| We won't reject your specimen if the forms are incomplete; however, our lab staff is required to send a copy to our billing office so they can try to gather any missing information before we begin to process the specimens. |
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Some Helpful Definitions |
| Client |
That's you: the lab, hospital, or practice group sending us a specimen |
| Patient |
Your patient |
| Subscriber |
Whose insurance policy is it? (e.g. the patient's own policy; or the patient's spouse or parent) |
| Primary vs. Secondary Insurance |
Primary = company that should be billed first. Secondary (if any) = company that should be billed for anything not covered by primary insurance. |
| SPAN (Self-Pay Authorization Number |
Call (336) 713-0164 or 716-9817 to have SPAN assigned when the patient is to be billed directly. We can not bill patients directly without pre-authorization. |
| ABN (Advance Beneficiary Notice Form |
See the HHS Quick Reference Guide here. These forms are required for certain procedures performed on Medicare patients. Once completed, the form is kept on file in your office. You do not need to send it to us |
| Primary Care Provider (PCP) |
Patient's regular Physician, Physician Assistant, Nurse Practitioner, etc. (if this is someone other than the person signing the request). |
If you complete the form by hand, please print clearly and legibly. The blanks are small, and we apologize for any inconvenience this causes. You may also complete the form on your computer (see above) if you have access to a computer in your specimen processing area. Please be sure to use the correct form(s) for the specimen(s) you are submitting.
- Client Information: This first section, in the top right-hand corner of the form, is for information about your hospital, clinic or practice group. An E-mail address is not required, but may be helpful if we need to contact you. The technician who prepares the specimen or completes the form should initial or print his or her name in the blank provided. (Leave the grey boxes for the WFUBMC case number and date received blank.)
- Complete with your current hospital/group/clinic contact information.
- Time-saving tip: Complete the Client Information section before you print the blank form or before you save it to your computer. If your address or phone number changes, you can change it on your saved form or print a new one with the correct information.
- Patient Information: This information is used to register the patient into our hospital's computer system; it is used for security purposes as well as unique identification. It is also used by the lab to help ensure that the patient's specimens and/or laboratory results are not confused with those of another patient with a similar name.
- Fill in all blanks (maiden name can be left blank if appropriate).
- Our registration system requires the patient's mother's first name, rather than her maiden name. This is for security and identification purposes.
- If you're completing the form on your computer, you'll see that the Marital Status and Race fields are drop-down boxes. The selections are determined by the North Carolina Baptist Hospital registration system's requirements.
- If you're completing the form by hand, the categories for Marital Status are: Single, Married, Widowed, Living w/ Partner, Living Separately (still married), Legally Separated, Divorced, and Unknown; the categories for Race are: Asian, Black, Hispanic, Native American, Other, Unknown, and White.
- Billing and Insurance Information: We cannot process your specimen until we have complete billing information, so please make every effort to include the most recent information from the patient's chart.
- Primary Insurance is the company to be billed first; secondary insurance includes all other policies. Provide the appropriate subscriber name, policy ID numbers, dates, and addresses in the space indicated.
- You can attach a copy of your own insurance forms and/or copies of both sides of the patient's insurance card(s) only if they contain all of the information requested; make sure that any abbreviations and codes are spelled out clearly. You must complete the rest of the request form in full. The rest of the form must be completed as it is a legal document and part of the patient's medical record.
- If you request that we bill the patient directly for this service, did you call the patient's insurance company to get authorization, if needed?
- If the patient has no insurance, please call us (at the numbers on the form) to get a Self Pay Authorization Number (SPAN) to enter in the appropriate space on the form. If you did not get a SPAN, your office will be billed. We can't bill self-pay patients directly without authorization.
- Medicare patients must have a signed Advance Beneficiary Notice (ABN) form on file with your office for all routine Pap tests. If you are submitting a routine Pap test specimen, check the box in the 'Medicare Information' section if you have a signed ABN form on file for the patient. Information about the ABN form is available here; copies of the form itself are here.
- Physician Information: This request form is a legal document, much like a prescription or any other physician order, and becomes part of the patient's medical record.
- Because this form is considered a physician's order, the ordering physician's signature is required by law. You may attach a copy of a written, signed order if you prefer.
- Please include the physician's telephone and fax number if different from those at the top of the form.
- We will be glad to fax a copy of the report to the patient's primary care provider if the 'send copy of report' box is checked and the provider's name and fax number are included.
- Complete for All Specimens:
- Record the collection date and time in the space provided as these may be important or relevant to the specimen analysis or the test results.
- Check the appropriate box to indicate whether the patient is an inpatient or an outpatient.
- In emergency cases, if you need the results quickly, check the URGENT box and provide an additional contact number if necessary.
- Surgical Pathology Specimens:
- Check the 'Surgical Pathology Specimens' box and type or write the requested information in the space provided. Click here if you need details about specimen preparation.
- You can send several surgical specimens (each must be properly labeled) with one form, but you must complete a separate form (or submit a copy) if you send both surgical and cytology specimens on the same patient at the same time.
- Cytology Specimens:
- Check the 'Cytology Specimens' box and type or write the requested information in the space provided. Click here if you need details about specimen preparation.
- You can send several cytology specimens (which must be properly labeled) with one form, but you must complete a separate form (a photocopy is fine) if you send both surgical and cytology specimens on the same patient at the same time.
- Dermatopathology Specimens:
- The first five sections on the Dermatopathology Request Form are to be completed as described in items 1-5 above.
- The final section asks for specific details about the specimen(s), the biopsy method and site, as well as a clinical description and diagnostic information.
- Please be sure to note any previous biopsy numbers (if applicable) on this patient.
- You may send several specimens from the same patient with one form. Click here for specimen preparation details.
- Renal Biopsy Specimens:
- The first five sections of the Renal Biopsy Request Form are to be completed as in items 1-5 above.
- The final section includes space for essential clinical information, patient history, and lab results.
- In addition, Dr. Iskandar's Renal Biopsy Collection Guide is included as the second page of the form. Click here if you need additional details about specimen preparation.
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