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Dermatopathology Requision Form

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Dermatopathology Requision Form
Surgical Pathology Label / Barcode
Johns Hopkins Dermatopathology & Oral Pathology Requisition Form – Wet/Fresh Tissue Submission 600 N. Wolfe Street – Blalock 907 Baltimore, MD 21287
Phone: (877) 321‐9444 toll free / (410) 955‐3484 Fax: (410) 955‐2445 Specimen Collection / Procedure Date: __________________________ Patient Info. (or place patient label over this section) History Number / MRN (or SSN): Last / First / MI: (Required) Submitting/Requesting Physician’s Signature: DOB:
_________________________________ Date & Time:_______________ **Please complete the section below in its entirety**
Submitting/Requesting Physician Last / First / Title:  male  female Clinic / Location: Other Physician to Receive Report JH Doctor # / NPI: Last / First / Title: City / State / Zip: Street Address / City / State / Zip: Fax: Phone / Pager: Phone / Pager: Fax: Clinical Description / History Biopsy for alopecia requiring horizontal sections? Special Stains/Studies Requested  yes  no Immunofluorescence (IF) analysis specimen(s) sent separately?  yes  no Biopsy Site [must exactly match label on specimen container]
Procedure
Clinical Diagnosis
1. 2. 3. 4. Insurance / Billing Information Policy Holder’s Name (Last / First / MI):  Medicare #, Letter:  Blue Shield #, Group, State:  Ins. Company: Policy #: Group #: Relationship to patient:
**if Medicare, please list secondary also.  Medical Asst. #:  Copy of insurance card attached Plan #: Auth. #: Patient / Guarantor Authorization I acknowledge my responsibility for all charges for these laboratory services requested on my behalf by my physician and authorize the release of information, including medical information, for this and any related claim, to the named insurance company. I also promise to pay for all charges for any of these laboratory services that are not covered or are only partially covered/authorized by my insurance or Health Maintenance Organization. Subscriber / Beneficiary Signature: ___________________________ Date: _______________________  Supplies needed: ________ specimen kits JHH 08‐80006322045 9/2010 CLIA License #21D0709101 / State of Maryland License #309 
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