Authorization Request Form

Authorization Request Form

This form may be used by a physician, client, or third party requesting an additional test(s) to be added to an existing report/case. This may also be used to request an amendment (correction) to an existing pathology report/case.

Authorization Request

Specimen details

Accession Number *

Requesting Physician *

Patient's details

Patient's Full Name *

Patient's DOB *

Patient's SS# *

Patient's Address *

Patient's City *

Patient's Zip Code *

Patient's Phone *

Insurance details

Primary Insurance *

Primary Insurance Policy # *

Secondary Insurance *

Secondary Insurance Policy # *

Requested changes

Describe change to be made *

Please read

By checking this box I confirm I am the requesting physician and agree to the associated changes as described in this form and understand this will be used as my electronic signature. *

Security check

reCAPTCHA *