AWDTS

PATHOLOGY REQUEST
MEDICARE CARD NUMBER
FILE NO.
PATIENT NAME

LAST NAMEGIVEN NAMES
MALE / FEMALE / UNKNOWN / OTHER
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TEL (HOME & MOBILE)
Please enter a valid phone number.Format: (000) 000-0000.
TEL (BUS)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
PATIENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cervical Screening

Rows
Doct
Copy 1
Copy 2
Copy 3
Hosp/Ward

TESTS REQUESTED
CLINICAL NOTES
BY TIME:
PHONE/FAX NO:
VET AFFAIRS NO:
DOCTOR’S SIGNATURE AND REQUEST DATE
DOCTOR'S SIGNATURE
REQUEST DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
COPY REPORTS TO:
REQUESTING DOCTOR (PROVIDER NUMBER, SURNAME, INITIALS, ADDRESS)
HOSPITAL/WARD

Was or will the patient be, at the time of the service or when thespecimen is obtained: (✓ appropriate box)

Rows	yes	no
a. a private patient in a private hospital or approved day hospital facility
b. a private patient in a recognised hospital
c. a public patient in a recognised hospital
d. an outpatient of a recognised hospital

PATIENT’S SIGNATURE AND DATE
MEDICARE ASSIGNMENT

(Section 20A of the Health Insurance Act 1973)

I offer to assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s) and any eligible pathologist determinable service(s) established as necessary by the practitioner. In the alternate, I authorise that APP to submit my unpaid account to Medicare so that Medicare can assess my claim and issue me a cheque payable to the APP for the Medicare Benefit.
PATIENT’S SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Practitioner’s Use Only
(Reason patient cannot sign)
PERSON DRAWING BLOOD
I certify that the blood specimen(s) accompanying this request was drawn from the patient named above. I established the identity of this patient by direct inquiry and/or inspection of wrist band and immediately upon the blood being drawn I labelled the specimen(s)
SIGNATURE
LAB USE
Collect Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coll. Time

Hour Minutes

AM/PM Option
Received Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rec. Time

Hour Minutes

AM/PM Option
Test Codes
Attachments
If yes, no. of pages
Attachments

Cancelof
Branch
Ref. No.
B/C
Clinic
Lab. No.
Description & Containers
Collector
USE OF PATIENT CONTACT INFORMATION
PATIENT SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Should be Empty:

PATHOLOGY REQUEST

DOCTOR’S SIGNATURE AND REQUEST DATE

PATIENT’S SIGNATURE AND DATE

LAB USE