Guidelines for Requesting Release of Pathology Material to Another Facility
To ensure a smooth and compliant process for the release of pathology material to another facility for a second opinion or continuation of care, please adhere to the following guidelines:
How to Facilitate or Submit a Request
To streamline your submission process, please follow these steps:
- Visit our website at sbmf.org/downloads to download the requisition form from the Test Requisitions section.
- Fill out all required sections accurately. This form is essential for processing your request.
- Once completed, print the form and fax it (574) 807-3162.
- A release of information form is required for second opinion requests to ensure proper authorization and compliance with HIPAA regulations. This form confirms the patient’s consent to transfer their medical information.
- For continuation of care requests, a signed release form is not required if the request is made directly by the patient’s healthcare provider, as it is considered part of ongoing treatment.
Required Information
Patient Information: Full name, gender and date of birth.
Ordering Physician Information
Billing Information: Please specify the party to be billed for consultative services, along with insurance details, ICD-10 codes, clinical history, and place of service. For inpatient cases, please also provide the discharge date.
Sample/specimen Information: Please provide the purpose of releasing material, the accession number, date of collection, body site, and indicate whether you would like slides and/or blocks to be sent.
Where to send pathology material: Name, address, phone and fax of the receiving facility, and a FedEx account number or label.
Patient Requests
SBMF advises patients to work through their physician or contact the facility they wish to send the material for specific instructions. In many cases, the receiving facility can handle the request on their behalf. Patients requesting their material must visit our location to sign a release of information form. To arrange this, please contact our office at 574-234-4176.
Location: Blood Donor Services, 3355 Douglas Road, South Bend, IN 46635. Please bring a photo ID.
Onsite Pickup: Patients may pick up their pathology material in person and hand-carry it to their appointment.
- A release form must be signed onsite.
- A $25.00 fee for slide retrieval will be invoiced. (CPT code 38056)
Shipment by SBMF: SBMF can ship the slides for you.
- A release form must be signed onsite.
- A $50.00 fee for slide retrieval will be invoiced. (CPT code 38407)
Processing Time
Requests will be processed in accordance with our standard turnaround times. (48 hours). Please allow adequate time for processing and shipping.
Q & A Section
Q: What if I don’t have a FedEx account number?
A: If you do not have a FedEx account number, please provide an alternative shipping method or billing details as required. Contact our department for assistance in arranging shipping or pick up.
Q: Can I submit the request form by email or fax?
A: Requests must be submitted by fax or patients may come onsite to fill out a release of information form. We cannot accept requests via email or phone. Our fax number is 574-807-3162
Q: What if the patient is unable to sign the release form?
A: If the patient is unable to sign the release form, they can provide consent through the authorization to treat documentation completed at the requestor’s facility. This documentation serves as proof of consent for the transfer of their medical information.
Q: What if I don’t have all the required information?
A: All required fields on the request form must be completed. If you are missing information, the form cannot be processed until all details are provided. Please gather the necessary information before submitting your request.
Q: Can patients pick up their pathology material themselves?
A: Yes, patients are welcome to come onsite to pick up their pathology material and hand-carry it to their appointment. We recommend that patients also contact their physician or the receiving facility for specific instructions on handling and transferring the material.
Q: Who should I contact if I have further questions about the guidelines?
A: For any additional questions or clarifications regarding the guidelines, please reach out to our pathology department at 574-234-4176.