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GENERAL REQUISITION
FORM
MASSACHUSETTS GENERAL HOSPITAL
NEUROGENETICS DNA DIAGNOSTIC LAB
DIV: 256 BA: 25601 - DNA LAB TESTING
TEST REQUESTED: __________________ REFERRING
MD: _____________________
PATIENT NAME ___________________ LOCATION:
________________________
last
first
PATIENT ADDRESS __________________
_________________________________
street
street
________________________ ___________ ______________________ _________
city, state zip
city, state zip
Telephone # ________________________ Tel
# _____________ Fax # _____________
DATE OF BIRTH _____ SEX M ___ F ___
MGH Unit # ________________________
PATIENT HISTORY
Is a family mutation known? YES
NO
If yes, what is the family member's name? ______________________________
What lab identified the mutation? ________________________ Lab#_________________
Is testing related to a current pregnancy? YES NO
PLEASE SEND PEDIGREE & IDENTIFY ALL RELEVANT FAMILY MEMBERS
BILLING INFO FOR PARTICIPATING INSTITUTIONS:
Institution Name: _________________________________________________________
Billing Address: __________________________________________________________
Contact Name: ____________________________ Phone Number: ___________________
Authorization Number: ______________________ Other Critical Info: ________________
BILLING INFO FOR NON-PARTICIPATING INSTITUTIONS
Please inform patient that he/she is required to prepay for this service.
Payment can be made by
either check or credit card payment. The patient can call (617) 726-5721 for
information if he/she wishes to seek reimbursement from health plan/insurer.
1. CHECK PAYMENT: Make check payable to MGH Neurogenetics
DNA Lab
Check # Amount:
2. CREDIT CARD PAYMENT (Complete the following information, cardholder's
signature is required)
Circle Credit Card Type: VISA MasterCard
AMEX
CARDHOLDER'S NAME: ________________________________
ACCOUNT NUMBER: __________________________________ Exp Date ___/___/___