Get Biotheranostics Cancer Type Id

2009 bioTheranostics Inc. All rights reserved. CLIA 05-D1065725 BIOTHERANOSTICS INC. 11025 ROSELLE STREET SUITE 200 SAN DIEGO CA 92121-1208 TOLL FREE 877 886-6739 CA CLF334843 BTX 0005 12/09 WEB5883. Insurance Carrier Name I hereby request and authorize bioTheranostics Inc. to utilize the above information to process the tumor specimen for the indicated patient. Biotheranostics. com 2. PATIENT INFORMATION 1. ONCOLOGIST INFORMATION Name NPI Email Social Security Number Practice Name DOB Address City State Phone Physician Direct Zip Fax Sex q M q F Medical Record Number Phone Alternate Phone Entering fax certifies fax equipment is located in a secure area. 3. Test Requisition Form THEROS CancerTYPE ID THEROS Breast Cancer Index Toll Free 877 886-6739 Fax 858 587-5888 www. PATHOLOGIST INFORMATION 4. SPECIMEN INFORMATION Block ID Number Biopsy Site Date Collected Date of Discharge or Outpatient Encounter Laboratory Name Fixative Type Sending Hospital/Facility Block Return Address Information if different from Section 3 5. BILLING INFORMATION ICD-9 Codes Required - List all codes that may apply. 6. TESTS PERFORMED Clinical Diagnosis Bill to q 10001 THEROS CancerTYPE ID q Insurance q Medicare q HMO Fill-in Medicare Information below Prior authorization required q Patient q Laboratory Account q Other Test for cancer classification q 20003 THEROS Breast Cancer Index Test for risk of breast cancer recurrence Combination H/I and MGI q Medicaid MEDICARE INFORMATION - Please check box for patient s hospital status when sample was sent. q Hospital Inpatient q Hospital Outpatient q Non-Hospital Patient Medicare Number Date of Specimen Collection 7. PHYSICIAN / PRACTITIONER CERTIFICATION PRIMARY INSURANCE INFORMATION - Please attach a copy front and back of patient insurance card s. I certify that the test is medically necessary and the results will be used in the management of the patient. I certify that I am authorized by law to request the test and I agree to provide the necessary information and records needed for billing. Policy Number/Member ID Signature Policy Holder Name Group Name Date Print Name Group Number Policy Holder DOB Relation to Patient Policy Holder Phone INCLUDE COMPLETED TEST REQUISITION FORM PATIENT INSURANCE DOCUMENTS AND PATHOLOGY REPORT WITH SPECIMEN IN SHIPPING KIT. ALL BLOCKS SUBMITTED WILL BE RETURNED FOLLOWING TEST COMPLETION* SEND SPECIMENS FEDEX STANDARD OVERNIGHT TO SECONDARY INSURANCE As a courtesy secondary insurance information may be submitted* Please provide a copy front and back of the secondary insurance card in addition to the following information secondary insurance carrier policy number group name and group number billing address and phone number policy holder name ID date of birth relation to patient and phone number. PATHOLOGIST INFORMATION 4. SPECIMEN INFORMATION Block ID Number Biopsy Site Date Collected Date of Discharge or Outpatient Encounter Laboratory Name Fixative Type Sending Hospital/Facility Block Return Address Information if different from Section 3 5. BILLING INFORMATION ICD-9 Codes Required - List all codes that may apply. 6. TESTS PERFORMED Clinical Diagnosis Bill to q 10001 THEROS CancerTYPE ID q Insurance q Medicare q HMO Fill-in Medicare Information below Prior authorization required q Patient q Laboratory Account q Other Test for cancer classification q 20003 THEROS Breast Cancer Index Test for risk of breast cancer recurrence Combination H/I and MGI q Medicaid MEDICARE INFORMATION - Please check box for patient s hospital status when sample was sent.