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Oral Pathology Biopsy Service

Please complete this form only when you have a specimen (in formalin or other medium) to submit.
If you would like a patient to be evaluated for pathology with a possible biopsy or additional testing, please use this form: (Comprehensive Clinical Pathology Services)

Please review what was entered. At the bottom you can print and/or save this form, or go back to make changes, or submit the form.
The referral request will not be complete until it is submitted.

Please Review

DATE: 3-26-2023

UNIVERSITY OF MICHIGAN - EXTERNAL REFERRALS
ORAL AND MAXILLOFACIAL PATHOLOGY BIOPSY SERVICE
Phone: (800) 358-1011
Fax: 734-764-2469
Email: umoralpath@umich.edu

Patient Agreement to Pay for Services. In the event that my medical health insurance and/or Medicare/ Medicaid does not pay for laboratory, diagnostic, and any other fees, I understand and agree that I will be responsible for payment in full to the University of Michigan Oral Pathology Biopsy Service.

If the patient's signature is not on file, please have them sign and date the printed version of this review that is sent.

Print Patient Name
If patient is a minor, print Parent/Guardian Name
Signature (Patient, Parent/Guardian)
Date

PATIENT: General
Name
DOB
Own legal guardian?
Gender If Provided
Phone & Email
Address
,

PATIENT: Medical
Medical Conditions
History of Cancer
Medications
Insurance
Insurance Details
Current Lesion(s) & Description

DESCRIPTION
Clinical Diagnosis
Nature of Operation
Surgical Findings
Systemic or Topical Steroids?
Prior Biopsy / Other Lab?

Other Lab Info

Uploaded Files
    Uploaded Files - Details

    Radiograph(s):
    Clinical Photo(s):
    CBCT Report:

    REFERRER
    Name
    Practice Name If Provided
    NPI# If Provided
    Phone & Email
    Address
    ,

    Patient Billing Policy & Agreement to Pay for Services

    Patient Notice of Billing Policy. As a result of evaluation by your dentist or physician a specimen is being sent to us for an oral pathologist’s diagnosis.

    Our fee for the diagnosis of your biopsy is separate from your dentist’s or physician’s fee for the biopsy procedure. The diagnosis of your biopsy is a medical (not dental) procedure. If your medical insurance information is included with your biopsy, we will submit a claim for you.

    If there is a balance due on your account, you will receive a statement. Please check with your insurance carrier. They may require a referral letter, PPO form, or prior authorization code from your primary physician.

    For questions concerning the bill and/or payment arrangements for your biopsy, please contact:

    APS Medical Billing
    Toll free phone: 800-678-1861

    1. Doctor Information

    (required)
    letters, spaces, hyphens, apostrophes
    (required)
    letters, spaces, hyphens, apostrophes
    (required)
    letters, spaces, hyphens, apostrophes

    numbers only, 10 digits required, or 15 if using prefix 80840
    (required)
    numbers, hyphens
    (123-123-1234)
    (required)
    numbers, letters, hyphens, apostrophes
    (name@example.com)
    (required)
    numbers, letters, spaces, hyphens, apostrophes
    (required)
    numbers, letters, spaces, hyphens, apostrophes
    (required)
    Only U.S. States are currently available
    (required)
    numbers, hyphen
    (format: 12345 or 12345-6789)
    Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
    To overwrite previously saved information, enter new information and click save again.

    2. Patient Information: General

    (required)
    (required)
    (required)
    (required)
    (required)
    (required)
    (required)

    (required)

    (required)

    3. Patient Information: Medical




    Please select one of the three options
    Note: if no medical insurance is entered, the patient will be billed directly.

    The field below is only required if Primary or Secondary insurance were selected above.

    If you do not have a scan of the insurance card, please enter the insurance details in the field below this message.

    If you have a scan of the insurance card, please upload the image(s) using the "Image Uploads" section near the bottom of the form and simply write "uploaded" in the text field just below this message.

    4. Patient Information: Current Lesion(s):

    If drawing multiple locations, please allow a brief pause between each (~1-2 seconds).
    If choosing different colors for different lesions, you can close the color picker by clicking the word "Draw."

    Draw


    Current Lesion(s)
    Please describe the lesion(s) and location of biopsy *
    Please indicate your clinical (differential) diagnosis.*
    Please indicate the nature of the operation (clinical procedure)*
    apicoectomy, curettage, enucleation, excision, incision, extraction, punch, other (please specify)
    Please indicate your surgical findings
    Is the patient currently using systemic or topical steroids?
    Did the patient have a prior relevant biopsy submitted to a laboratory other than the University of Michigan?*
    If yes, please provide information so that we can retrieve the report (referring doctor's name and location)

    Image Uploads

    (required) Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
    Add File or Image
    Please let us know about your uploads *
    Radiograph(s)?
    Clinical Photograph(s)?
    CBCT Report?

    Patient Signature: Please note that a patient signature needs to accompany the biopsy submission form for the sample to be processed.

    To save the review page as a file, click "Print this page" and choose "save as pdf" from your printer's options.