Medicare will only pay for services that are reasonable and necessary for the diagnosis and treatment of the patient. The physician must specify an ICD code to indicate the medical necessity of each test requested. 300 Pasteur Drive, Room H2110 ● Stanford, CA 94305-5624 Phone: (650) 723-6736 ● Attending Direct Line: (650) 796-9100 ● Fax: (650) 725-7409 Patient Name (Last) (First) Date Of Birth Practice Name & Address . o N x a F . o N e n o h P Physician Signature - REQUIRED Date For Lab Use Only Referring Facility MRN Sex Patient’s Phone Number Patient Address Cit y State Zip Code Technical (lab) and professional (M.D.) charges are billed separately. Insurance Info: Attach a copy of front & back of Insurance card or face sheet. M F ( ) Physician Name Physician NPI #: (Name & Address, Fax & Phone) Kerri Rieger, MD, PhD ● Roberto Novoa, MD ● Ryanne Brown, MD Dermatopathology Requestor Information Patient Information Requesting Physician COPIES TO: HMO Insurance Authorization # Patient PPO HMO* Client Medicare Inpatient Outpatient *Referring facility is responsible for obtaining HMO authorization. If claim is denied due to lack of authorization, the referring facility will be billed for services. BILL TO: 15-2304 (7/18)

Stanford Labs Requisition: Dermatopathology (old)

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Page 1: Stanford Labs Requisition: Dermatopathology (old)

300 Pasteur Drive, Room H2110 ● Stanford, CA 94305-5624 Phone: (650) 723-6736 ● Attending Direct Line: (650) 796-9100 ● Fax: (650) 725-7409

Patient Name (Last) (First) Date Of Birth

Practice Name & Address

.oN xaF.oN enohP

Physician Signature - REQUIRED

Date

For Lab Use Only

Referring Facility MRN Sex Patient’s Phone Number

Patient Address City State Zip Code Technical (lab) and professional (M.D.) charges are billed separately.Insurance Info: Attach a copy of front & back of Insurance card or face sheet.M F ( )

Physician Name Physician NPI #:

(Name & Address, Fax & Phone)

Kerri Rieger, MD, PhD ● Roberto Novoa, MD ● Ryanne Brown, MD

Dermatopathology

Requestor Information

Patient Information

Requesting Physician

COPIES TO:

HMO Insurance Authorization #

Patient PPO HMO* Client Medicare

InpatientOutpatient

*Referring facility is responsible for obtaining HMO authorization. If claim is denied due to lack of authorization, the referring facility will be billed for services.

BILL TO:

15-2304 (7/18)