Miraca Life Sciences Urologic Pathology Requisition
GU000000
CLIENT INFORMATION
PLEASE CHECK REQUESTING PHYSICIAN
REFERRING PHYSICIAN:
Last, First: ________________________________________ Fax: ___________________________
REQUESTING PHYSICIAN
PATIENT INFORMATION
(All shaded areas are required information)
BILLING INFORMATION (Attach back/front of patient insurance cards)
Please attach patient face sheet and front and
back of primary and secondary insurance card(s)
}
Primary Insurance:
Medicare
Patient Status:
Non-Hospital Patient
See Attached
Patient, Client and Billing Information is requested for timely processing. Medicare and other third party payors
require that services be medically necessary for coverage, and generally do not cover routine screening tests.
Relationship to
Policy Holder:
Name (Last, First): _______________________________________________________________
Date of Birth:
/
/
Sex: M F
REQUESTING PHYSICIAN
}
Self
Spouse
Insurance
Patient Bill
Client Bill
Hospital Inpatient
Hospital Outpatient
Child
Other _____________ Referral #: ___________
Insurance Name: __________________________________________________________________
SSN# XXX-XX-________________
Policy #: ________________________________ Group#: _________________________________
Address: _______________________________________________________________________
Policy Holder Name: _________________________________________ DOB: _____/_____/_____
City: ___________________________ State: ___________________ Zip: __________________
Address: __________________________________________ Phone #: ______________________
Home Phone #: ___________________________ Work Phone #: _________________________
City: _____________________________________________ State: _________ Zip: ____________
Medical Record #: _______________________________________________________________
Secondary Insurance: ______________________________________________________________
Order ID #: _____________________________________________________________________
Policy #: ________________________________ Group#: _________________________________
CLINICAL INFORMATION (ICD-10 Codes provided are subject to change)
Collection Date:
/
/
Collection Time: ________________ Clinical History: ____________________________________________________________
_____________________________________________________________________________________________________________________________________________
PROSTATE ICD-10 Codes
R97.2
N40.0
Z85.46
C61
N41.0
N41.1
BLADDER ICD-10 Codes
Elevated PSA
Enlarged prostate
History of prostate cancer
Malignant neoplasm of prostate
Acute prostatitis
Chronic prostatitis
TC ACCTS REQUIRED:
R31.9
R31.0
R31.1
R31.2
OTHER
Hematuria, Unspecified
Gross Hematuria
Benign essential microscopic hematuria
Other microscopic
N30.00
N30.01
N30.10
N43.1
Malignant Neoplasm of the Bladder
C67.0Trigone
C67.9Unspecified
C67.1Dome
Z78.9 Other specified health status
C67.2 Lat Wall
Z74.09 Other reduced mobility
If not checked,
default to TC only
TC ONLY
GLOBAL
Acute cystitis without hematuria
Acute cystitis with hematuria
Interstitial cystitis without hematuria
Interstitial cystitis with hematuria
C67.3 Ant Wall
C67.4 Post Wall
C67.5Neck
CONSULTATION
Please include
case slides
____________________
Please provide code:
_____________________
C67.6 Ureteric Orifice
C67.7Urachus
C67.8 Other specified
Opt out of approved protocol
HISTOLOGY
Prostate – # of Jars: _____________
Vas Deferens – L
Bladder – # of Jars: ______________
Other: _________________________
Vas Deferens – R
1 Positive Cores (highest Gleason Score)
2 Positive Cores (highest Gleason Score, one from each side)
All Positive Cores
DNA Match on Positive Biopsy
Previous Biopsy:
None
Benign
Suspicious/ASAP
HGPIN
Malignant
Collection Method:
TURBT
Needle Core Biopsy
TURP
Cold Cup Biopsy Forceps
Other: _______________________________
Clinical Findings:
DRE:
Normal
Abnormal
Last PSA: _______ ng/mL, Date:
/
/
Clinical Stage:
T1c
T2a
T2b
T2c
(Please complete this section (Clinical Findings) to receive a Partin Table on positive prostate biopsy reports)
CYTOLOGY & FISH
Cytology
Cytology
Cytology Plus
Pap & Feulgen Stain
Bladder FISH
UroVysion™
REFLEX to FISH if :
Negative Cytology
Atyp./Susp. Cytology
Positive Cytology
Collection Method:
(Required Information)
Voided Urine
Catheterized
Hematuria Analysis*
Dipstick Urinalysis Includes:
Cytology with UroVysion
Cytology PLUS with UroVysion
Cytology with Hematuria Analysis
Cytology PLUS with Hematuria Analysis
Hematuria PLUS Profile: Includes Pap & Feulgen
Glucose, Bilirubin, Ketone, Specific Gravity,
Blood, PH, Protein, Urobilinogen, Nitrate,
Leukocytes, Sediment Analysis
Stain Cytology, UroVysion, Hematuria Analysis
Ileal Conduit
Post Cystoscopy
Bladder Wash
Other: ___________________
Ureteral Wash
Renal Wash
L
L
R
R
PROGNOSTIC/OTHER TESTING
*(minimum of 8 cores required)
REFLEX if:
Prostate Biopsy-Negative (all negative cores tested)
Prostate Biopsy-HGPIN (all HGPIN and negative cores tested)
PCA3, Prostate Cancer Gene 3 Assay* Myriad Prolaris*
PTEN FISH on Prostate Biopsy
REFLEX if :
HGPIN
PCa Gleason 6
PCa Gleason 7 (3+4 only)
Kidney Stone Analysis*, Site: _____________________________
Oncotype Dx*
Other: ________________________________________________
*Not available as TC
825 Rahway Ave., Union, NJ 07083 / 800.440.7284 / Fax: 908.349.3107 / CLIA 31D0909259
6655 N. MacArthur Blvd, Irving, Texas 75039 / 866.588.3280 / Fax: 866.688.3280 / CLIA 45D0975010
1 – Complete all requested information on requisition. 2 – Fill out appropriate labels below and place applicable label on each container.
Left Lateral Base
GU000000
Name _______________DOB_______
Left Lateral Mid
GU000000
Name _______________DOB_______
Left Lateral Apex
GU000000
Name _______________DOB_______
Left Seminal Vesicle
GU000000
Name _______________DOB_______
Left Base
GU000000
Name _______________DOB_______
Left Mid
GU000000
Name _______________DOB_______
Left Apex
GU000000
Name _______________DOB_______
Left Transitional
GU000000
Name _______________DOB_______
Right Base
GU000000
Name _______________DOB_______
Right Mid
GU000000
Name _______________DOB_______
Right Apex
GU000000
Name _______________DOB_______
Right Transitional
GU000000
Name _______________DOB_______
Right Lateral Base
GU000000
Name _______________DOB_______
Right Lateral Mid
GU000000
Name _______________DOB_______
Right Lateral Apex
GU000000
Name _______________DOB_______
Right Seminal Vesicle
GU000000
Name _______________DOB_______
Lateral Base #2
GU000000
Site ____________________________
Name _______________DOB_______
Lateral Mid #2
GU000000
Site ____________________________
Name _______________DOB_______
Lateral Apex #2
GU000000
Site ____________________________
Name _______________DOB_______
Bladder/Other
GU000000
Site ____________________________
Name _______________DOB_______
Bladder Biopsy
GU000000 Left
GU000000 Right
GU000000 Urine
GU000000 Bladder/Other
GU000000
Site ____________________________
Site ____________________________
Name _______________DOB_______ Name _______________DOB_______ Name _______________DOB_______ Name _______________DOB_______ Name _______________DOB_______
Top Copy – Miraca Life Sciences
Bottom Copy – Client
©2015 Miraca Life Sciences, Inc. All rights reserved. GUP001 REV. 9.15 MLS-20-0401.0