Pathology Request Form

PATHOLOGY REQUEST FORM

APPLICANT DETAILS

UHG /HSN ID NUMBER: ______

GIVEN NAME: / SURNAME:
ADDRESS:
STATE: / POSTCODE:
DATE OF BIRTH: / MALE: / / FEMALE: /

PATHOLOGY DATA ENTRY (Laboratory Use Only)

DR DETAILS Duplicate Copy Results To

RESULTS TO: Fax (03) 9692 7818 [auto fax] / Copy To DR NAME:
DOCTOR/ACCOUNT NAME: UHG (Life Insurance Solutions) / CopyToDR FULL ADDRESS:
SYMBION/SDS Dr Code:UUUH
GRIBBLES/ GPL Dr Code UNIF / SYMBION/SDS Billing Code: UHI
GRIBBLES /GPL Billing Code: V4544
IMVS Dr Code:UHCG
SONIC Dr Code: UHI / IMVS Billing Code:UHCG
SONIC Billing Code:
Barrat & Smith: Z uhg
Douglas Hanly Moir: I 1297 / Unified Healthcare Group Insurance / SUBURB:
Melbourne/IML Path: TXU14
Launceston / North West Path: H855 / STATE: / POSTCODE:

TEST REQUESTED FOR LIFE INSURANCE PURPOSES (Collector to clearly mark all tests requested with an X)

MBA 20 / (U& E’s, Glucose, LFTs, Creatinine ,Urea, eGFR, Calcium –total /adjusted /corrected, Phosphate, Cholesterol, Triglycerides)
HDL/LDL Lipids
Hepatitis B Surface Antigen + Hepatitis C Antibody COLLECTOR INSTRUCTIONS
HIV / ESR / PSA / Number of Hrs Fasting ______
Glucose / X / Iron Studies / Cotinine / FASTING: / NO / /
YES
HbA1c / Thyroid Function Test / 24 Hr Creatinine
Clearance / Indicate Number Tubes Actually
Collected below
FBC / Liver Function Test / MSU - Urine / SST ( 2 Maximum )

EDTA( 1 Maximum)
Other ……………………………………………………………………………………………….... /
Fluoride Oxalate (Gluc) (1)
Collect all listed tubes Max Volume

Laboratory Instructions: Tests Urgent 

Please store all tubes for Maximum period for possible further testing.

UHG is NOT responsible for any tests other than those requested above required for life insurance purposes.

IDENTIFICATION & COLLECTOR’S DECLARATION (Collector to Sign and Complete)

The Applicant has provided me with photographic identification confirming his/her identity. Type of identification provided:
/ Drivers Licence / / Passport / / Other (please specify) ______
I certify that the signature on this form and the specimens collected are from the above named and identified applicant
Print Name of Collector ……………………………………………………………….. / Collection Time: ______AM / / PM /
Signature of Collector …………………………………………………………………. Date ……………/…………………/………………

PRIVACY STATEMENT & PATIENT/INSURANCE APPLICANT’S DECLARATION (Applicant to Sign)

Unified Healthcare Group (UHG) has been engaged to collect blood and/or other personal medical information on behalf of the Insurance Company. UHG is bound by the requirements of the Privacy Amendment (Private Sector) Act 2000. This information is passed directly to those companies involved in your insurance application. UHG does not accept any responsibility for any distribution of your personal medical information once it has been delivered. UHG is prohibited from informing any applicant of this medical information.I certify that the specimens collected are my own and I consent to the analysis of the specimens and the release of the results to UHG and the Insurance Company to form part of the basis of my proposed insurance. I authorise additional reflex tests to be conducted on the specimens if required under the guidelines set by the Insurance Company. I acknowledge and confirm that I have received information about HIV, Hepatitis B and Hepatitis C testing if these tests are to be performed. In the event of a positive HIV, Hepatitis B or Hepatitis C test result I acknowledge that the insurance company’s Chief Medical Officer will be notified and will be responsible for informing me directly unless I have nominated my own doctor to receive these results. I understand that if I wish to get the results of these tests I should provide my doctor’s details and arrange my own appointment.
Signature of Applicant:…………………………………………………………………… Date ……………/………………/…………………