MEDICARE CARD NUMBER – IRN
BARCODE
PATIENT LAST NAME / ADDRESS GIVEN NAMES SEX DATE OF BIRTH YOUR REF:
TEL (BUS)TEL (HOME)
TESTS REQUESTED
MEDICARE CARD NUMBER – IRN
TESTS REQUESTED
CLINICAL NOTES
Fasting Non-fasting Diabetic Thyroxine Antithyroid
Urgent Phone Fax By Time:
Phone/Fax No:
Private Schedule Medicare
Vet Affairs:
COPY REPORTS TO:
HOSPITAL/WARD
Collector Declaration: I certify that I collected the accompanying sample from the
above patient whose identity was confirmed by enquiry and that I labelled
the sample immediately following collection. Collector’s Signature
✗ ........................................................................
Fasting
Non Fasting
Pregnant
Horm Therapy
LNMP
EDC
CERVICAL CYTOLOGY
SITE Cervix
Vaginal Vault
Endometrium
Other
Post Natal
Post Menopausal
Radio Therapy
IUCD
Abnormal Bleeding
Benign
Suspicious
Patient status at the time of the service or when the specimen
was collected
a) Private patient in a private hospital or approved day hospital facility
b) Private patient in a recognised hospital
c) Public patient in a recognised hospital
d) Outpatient of a recognised hospital
yes no
APPEARANCE
OF CERVIX
DOCTOR’S SIGNATURE AND REQUEST DATE
✗ ........................................................................................... DATE .........../ .......... / ............
LAB USE
REQUESTING PRACTITIONER (Provider No., Surname, Init., Address)
REQUESTING PRACTITIONER (Provider No., Surname, Initials, Address)
SELF DETERMINED
PATIENT COPY
Specialist Diagnostic Services Pty Ltd ABN 84 007 190 043 APA No 000042 trading as Laverty Pathology
R R
ACC STAMP
Collection Time Hours p.c. Hours post dose
:
: :
Pathology Request
60 Waterloo Road, North Ryde NSW 2113
www.laverty.com.au
RESULTS ENQUIRIES 13 39 36
Pathology Request
60 Waterloo Road, North Ryde NSW 2113
www.laverty.com.au
Specialist Diagnostic Services Pty Ltd ABN 84 007 190 043 APA No 000042 trading as Laverty Pathology
PATIENT LAST NAME / ADDRESS GIVEN NAMES SEX DATE OF BIRTH YOUR REF:
TEL (BUS)TEL (HOME)
I refer to assign my right to benefits to the approved pathology practitioner ("APP") who will render the requested pathology services and any eligible
pathologist determinable service(s) established as necessary by the practitioner. Alternatively, I authorise APP to submit my unpaid account to
Medicare so that Medicare can assess my claim and issue a cheque to me, payable to the APP for the Medicare Benefit.
PATIENT SIGNATURE ✗ ....................................................................................................................................... DATE ............../ ........... / .............
CERVICAL SCREENING TEST: Practitioner Collect Self-Collect
LBC AND HPV TESTS NOT MEETING CRITERIA ARE NOT COVERED BY MEDICARE.
CERVICAL SCREENING TEST: Practitioner Collect Self-Collect
LBC AND HPV TESTS NOT MEETING CRITERIA ARE NOT COVERED BY MEDICARE.
PT Claim
Form
Pyr AC
COLL SUBM DV REF PAT
Collected By Collect Date
TUBES URINES SWABS
EDTA CIT SST Plain Fluoride HEP Other Spot 24 Hr MICRO VIRAL Other
CONTAINERS HISTO SLIDES OTHER SRA USE
Faeces Semen LBC Other PAP MICRO Other Describe Sign Date Time
Accredited for compliance with
NPAAC Standards and ISO 15189
Accreditation No. 2203
DO NOT SEND REPORTS TO MY HEALTH RECORD
Learn about your tests
knowpathology.com.au
CLEAR SAVE
Your treating practitioner has recommended that you use Laverty Pathology. You are free to choose your own pathology provider. However, if your treating practitioner
has specified a particular pathologist on clinical grounds, a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your
treating practitioner.
PRIVACY NOTE: The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of
government health programs, and may be used to update enrolment records. Its collection is authorised by provisions of the Health Insurance Act 1973. The information
may be disclosed to the Department of Health and Ageing or to a person in the medical practice associated with this claim, or as authorised/required by law.
LAV-RF050_AV_2_Jun20
