MOFFITT MEDICAL GROUP AT MOFFITT CANCER CENTER
Pathology Consultation Request Form
12902 Magnolia Drive, MCC – 2nd Floor, Room 2049, Tampa, Florida, 33612
Telephone 813-745-3001 Fax 813-449-6680
REFERRING PHYSICIAN & INSTITUTION INFORMATION
Referring Physician Telephone
Point of Contact Telephone
Institution Billing Contact Name
Institution Billing Contact Email
Institution Billing Contact Telephone
SPECIMEN INFORMATION
Hematopathology Consultation Only
☐ Bone Marrow/Peripheral Blood (Current peripheral blood values must be submitted along with any bone marrow sample for review)
☐ Lymph nodes/other tissue for lymphoma diagnosis (Submission of block or 5-10 unstained sections is generally required if IHC’s confirmation is requested)
Flow Cytometry Only: ☐ Report Only ☐ Histograms/Raw Data
PATIENT INFORMATION
BILLING/INSURANCE INFORMATION
BILL TO:
☐
Facility/Referring Physician
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☐
☐
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Patient Insurance
(Attach Patient Demographic Sheets or complete required information below)
Discharge Date
Primary Insurance Company Name
Secondary Insurance Company Name
Primary Insurance Policy #
Primary Insurance Group #
Secondary Insurance Group #
Secondary Insurance Policy #
Name of Insured for Primary
Name of Insured for Secondary
(Required for billing)
Insurance Pre-Authorization #
(If applicable)
This request to order tests from Moffitt Medical Group (MMG) certifies that (1) the referring physician has obtained written informed consent from the patient as
required by applicable state or federal laws for each test ordered, (2) the referring physician has authorization from the patient as required by applicable state or
federal laws permitting MMG to provide the service and report results to the referring physician and (3) referring entity is responsible for obtaining preauthorization
from the payer if required. If the consultation request form is incomplete, the slides will not be reviewed until all required information is complete. If payment is
denied by the patient's insurance, the ordering institution will be invoiced for the services and will be responsible for payment. For Medicare patients classified as
a hospital inpatient or outpatient on the date of service, charges must be billed to the ordering institution.
Required Referring Physician/Pathologist Signature
