Guidelines for Outside Pathology Consultation Requests
We welcome requests from healthcare providers and facilities seeking second opinions on pathology cases.
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 and ensuring proper identification of the patient and materials.
- Once completed, print the form and include it with your shipment of pathology materials.
- 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 consultation, the accession number, date of collection, body site, and indicate how many slides and/or blocks are being sent.
Where to send pathology material: Name, address, phone and fax of the receiving facility, and a FedEx account number or label. This allows us to ship the materials back to your facility efficiently after the review is completed. Without this, we cannot process the return shipment.
Please include all related pathology reports, including those from prior biopsies.
Additional Testing Consent
SBMF may recommend additional testing, such as molecular, genetic or immunohistochemistry (IHC) studies, to assist in diagnosis. Ensure the following is understood:
Consent for Additional Testing: Indicate on the requisition form whether you authorize additional testing. Please note that additional charges may apply, and your office may be responsible for obtaining patient consent if necessary.
Billing for Additional Tests: For molecular testing, we will follow all applicable CMS guidelines, includeing the 14-day rule, and may delay testing accordingly.
Turnaround Time
Consultations: Routine cases are typically completed within 5-7 business days from receipt of the materials. Complex cases or those requiring additional testing may take longer.
Additional Testing: If additional tests are required, turnaround times may vary based on the complexity and type of testing. We will notify you if extended time is needed.
Shipping Instructions
Packing Materials: Use secure packaging, including slide boxes and padded envelopes, to protect materials during transit.
Shipping Address:
South Bend Medical Foundation
ATTN: Pathology Consults/Surgical Records
3355 Douglas Rd., South Bend, IN 46635
Phone: (574) 234-4176
We use FedEx for both sending and receiving materials. We DO NOT offer Saturday Delivery.
Additional Testing (Molecular/IHC)
If you require Molecular or Immunohistochemical (IHC) testing, please fill out a separate requisition form from our Downloads page.
Contact Information
For any questions or concerns about submitting materials, feel free to contact our office at (574) 234-4176.