ANATOMIC PATHOLOGY CONSULTATION SERVICE

1 ANATOMIC PATHOLOGY CONSULTATION SERVICE . 300 Pasteur Drive, Room H2110 Stanford, CA 94305-5624 . Phone: (650) 723-7211 Fax: (650) 725-7409. Christina S. Kong, MD, Medical Director URL: Patient Information BILL TO: Patient Name (Last) (First) Date Of Birth Patient PPO HMO* Client Medicare Outpatient HMO Insurance Authorization # Inpatient Referring Facility MRN Sex Patient's Phone Number *Referring facility is responsible for obtaining HMO authorization. If claim is denied due for lack of authorization, the referring facility will be billed for services M F ( ). Insurance Info: Attach a copy of front & back of Insurance card or face sheet. Patient Address City State Zip Code Technical (lab) and professional ( ) charges are billed separately. Requestor Information Practice Name & Address For Lab Use Only Physician Email: Phone No.

2 Fax No. Requesting Physician Physician Name Date Physician NPI #: Physician Signature - REQUIRED. (Name & Address, Fax & Phone). COPIES. TO: SERVICES REQUESTED: ATTENTION: Slide CONSULTATION Surgical PATHOLOGY - Subspecialty (list): _____. Wet Tissue CONSULTATION Cytopathology Dermatopathology Molecular Tests on Solid Tumors _____. Hematopathology _____. Neuropathology Other_____ Pediatric PATHOLOGY _____ Specific Pathologist (list):_____. Clinical Information/Consult Question: Specimen A Specimen B. Collection Date: ____/_____/_____ Case No. _____ Collection Date: ____/_____/_____ Case No. _____. Specimen Site: _____ Specimen Site: _____. QTY Identification QTY Identification _____ Unstained Slides _____ _____ Unstained Slides _____. _____ Stained Slides _____ _____ Stained Slides _____.

3 _____ Paraffin Block _____ _____ Paraffin Block _____. _____ Fresh Tissue _____ _____ Fresh Tissue _____. MARCH 2017.