Specimen Submission, GeneralSPECIMEN REQUISTIONS
The requisitions supplied by Cunningham Pathology facilitate surgical specimens, cytology specimens and molecular specimens. Please note that each requisition has several barcode labels affixed to assure patient and specimen integrity. That form must be completed as follows:
• Full name (no nicknames please *prior last names are also helpful*)
• Complete address
• Social Security Number
• Date of Birth
• Requesting Physician (we will be glad to provide any other physician you request with a
copy of the report)
• Federal Law requires the ordering physician or his designee to sign the request for testing
• Date and Time of Specimen Collection (These are important for some tests and for billing)
• Material Submitted:
o Cytology: Mark (x) by the appropriate test and source
o Molecular: Mark (x) by the appropriate test panel or write in the requested test panel
in the material submitted space
o Histology: Material submitted should be filled out along with any other test requested
• Clinical History and Procedure (see specific instructions for cytology and molecular)
• Billing instructions (In order for us to bill the patient's insurance, we must have
• An ABN (we furnish) must be signed by all Medicare patients when tests are ordered
that Medicare does not routinely cover, i.e. pap smears, cosmetic surgery, etc. –
We cannot bill the patient for a test if Medicare denies payment.
• The name of the insurance company (we will also take secondary insurance information).
• The insurance company's address.
• The subscriber (if not in the patient's name) and all subscriber information.
• We will be glad to accept a legible copy of the front and back of the patient's insurance
card in lieu of completing the information on the form.
NOTE: If you provide Cunningham Pathology with a legible copy of your up-to-date patient data sheet, the patient's name, physician information, and date of service is all the patient data that must be completed on the requisition form. We must, however, have the material submitted and clinical history included on the form.
• Label containers used for blood and other specimens in the presence of the patient.
• Each container must be labeled with the patient's name, date obtained, and the site of origin.
o NOTE: All specimen containers are required by CLIA to have at least two
• Place a barcode label from the requisition on the side of the container.
• Specimen container lids must be securely tightened.
• Specimen container must be placed in biohazard bags for transporting.
• Requisitions must be placed in the designated pouch of the biohazard bag.
• In all cases of specimen submission, Universal Safety Precautions are to be followed.
• Glass slides must have the patient name pencil written on the frosted side (specimen side)
of the slide.
• Specific instruction for specimen types are listed in the following pages:
By following the procedures for the requisition and specimen submission, very little follow-up will be necessary; however if clarification and/or corrections are needed a member of the Cunningham staff will contact the submitting facility/physician. All corrections on submitted material require the client's signature and the Cunningham staff member's signature on the corrected information. Rare instances may require return of the specimen to the client.
CONSULTATIONS (MATERIAL FROM OTHER LABORATORIES)
Review of patient slides for consultation or secondary review is available. The surgical specimen or consultation slides must be accompanied by history and include the patient's name. When requesting material from other institutions for a Cunningham pathologist to review, it is desirable to request the paraffin blocks to permit duplicate slide preparation. Also, a copy of the pathology report form the other institution must accompany the material. When original slides are submitted Cunningham Pathology will return them to the referring lab after a final report has been issued. A copy of the Cunningham Pathology report will also be sent to the referring lab.
924 Montclair Road, Suite 200, Birmingham, Alabama 35213 P: 888.553.8584 F: 205.591.5051