Requisition Form - Histopathology

Requisition Form - Histopathology
2500 E T C Jester Blvd #201 Houston, TX 77008
T: (713) 485-6965
F: (832) 218-1090
E: support@moduslaboratories.com
CLIA ID: 45D2245388
Provider Information
Group Name*
Practice Name
Provider Name*
Patient Information
Please complete all sections of this requisition form with accurate patient and clinical details. This helps ensure compliance with state and federal regulations and supports timely, accurate processing of results.
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Patient Allergies*
Billing Information
Primary Insurance Name*
Primary Insurance ID*
Primary Insurance Group No*
Is there a secondary insurance?

YesNo
Secondary Insurance Name
Secondary Insurance ID
Secondary Insurance Group No
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Collection Details
Sample 1 Collection Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample 1 Anatomical Location*
Sample 1 Diagnostic Codes*
Sample 1 Collection Type*

BiopsyExcision

Sample 1 Type*

	Left	Right
Skin / Soft Tissue: Dermatitis (Tinea / Eczema / Stasis)
Skin / Soft Tissue: Pigmented Lesion (Nevus / Melanoma / Lentigo)
Skin / Soft Tissue: Tumor (Verruca / IPK / Carcinoma)
Skin / Soft Tissue: Ulcer (Rule out neoplasm)
Nail Unit: Nail Dysrtrophy (Onychomycosis / Psoriasis / Trauma)
Nail Unit: Periodic Acid-Schiff (PAS)
Nail Unit: Pigmented Lesion (Nevus / Melanoma / Lentigo)
Nail Unit: Tumor (Verruca / IPK / Carcinoma)
Nail Unit: Ulcer (Rule out neoplasm)
Bone: Osteomyelitis (Infectious)
Bone: Tumor (Cyst / Neoplasm)
Bone: Degenerative Joint Disease
Mycology Sterile: Hair
Mycology Sterile: Skin
Mycology Sterile: KOH
Mycology Sterile: Nail
Mycology Sterile: Culture
Mycology Sterile: Culture (with ID)

Sample 2 Type*

	Left	Right
Skin / Soft Tissue: Dermatitis (Tinea / Eczema / Stasis)
Skin / Soft Tissue: Pigmented Lesion (Nevus / Melanoma / Lentigo)
Skin / Soft Tissue: Tumor (Verruca / IPK / Carcinoma)
Skin / Soft Tissue: Ulcer (Rule out neoplasm)
Nail Unit: Nail Dysrtrophy (Onychomycosis / Psoriasis / Trauma)
Nail Unit: Periodic Acid-Schiff (PAS)
Nail Unit: Pigmented Lesion (Nevus / Melanoma / Lentigo)
Nail Unit: Tumor (Verruca / IPK / Carcinoma)
Nail Unit: Ulcer (Rule out neoplasm)
Bone: Osteomyelitis (Infectious)
Bone: Tumor (Cyst / Neoplasm)
Bone: Degenerative Joint Disease
Mycology Sterile: Hair
Mycology Sterile: Skin
Mycology Sterile: KOH
Mycology Sterile: Nail
Mycology Sterile: Culture
Mycology Sterile: Culture (with ID)

Patient Acknowledgment

(Optional)
This specimen was provided voluntarily for analysis, and I authorize Modus Laboratories to process, bill and provide results.

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Authorized Healthcare Provider Acknowledgment

(Required)
By signing below, I hereby request and authorize the reference/testing lab to utilize this information to perform the testing for the indicated patient. I verify that I am the authorized provider of health care ordering this test as medically necessary to the assessment, diagnosis, or detection of disease, illness, symptom, disorder, or other health-related issue. If the undersigned provider checks off a panel as the provider’s choice, Modus Laboratories understands that the provider has determined that all of the component tests are medically necessary, and will perform, report and bill for all such component tests. I hereby further authorize Modus Laboratories to send, in its judgment, the patient specimen to another reference laboratory for testing on the reference laboratory's similar test panel(s), and all the component tests, as shared with me and as may be updated from time to time.*

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Date*

MonthDayYear
Notes
Should be Empty:

Provider Information