CYTOPATHOLOGY

300 Pasteur Drive, Room H2110 ● Stanford, CA 94305-5624 ●

Phone: (650) 736-9861 ● Fax: (650) 725-7409
Brittany J. Holmes, MD, Cytopathology Director
www.stanfordlab.com

Patient Information BILL TO: ABN is Located on Last Page

Patient Name (Last) (First) Date Of Birth Patient PPO HMO* Client Medicare
Outpatient
HMO Insurance Authorization # Inpatient
Referring Facility MRN Sex Patient’s Phone Number
*Referring facility is responsible for obtaining HMO authorization. If claim is
M F ( ) denied due for lack of authorization, the referring facility will be billed for services
Insurance Info: Attach a copy of front & back of Insurance card or face sheet.
Patient Address City State Zip Code
Technical (lab) and professional (M.D.) charges are billed separately.

Collection Date Time in Formalin

(REQUIRED) (REQUIRED for breast FNA)

Requestor Information
Practice Name & Address For Lab Use Only

Physician Email:
Phone No. Fax No.

Requesting Physician

Physician Name Date Physician NPI #: Physician Signature - REQUIRED

(Name & Address, Fax & Phone)
COPIES
TO:

GYN CYTOLOGY SPECIMENS: PAP TEST

Last Menses (LMP Date): Previous Abnormal Pap - Date/specify:
SPECIMEN LABELS
Postmenopausal Pregnant Postpartum Chemotherapy? No Yes, When:
Radiation? No Yes, When: Current Hormone Therapy? No Yes, Specify:
Check For All Medicare Patients Low Risk Screening High Risk Screening Diagnostic Pap Smear
Specimen Source (Required): Cervical/Vaginal Vaginal Anal
TESTS REQUESTED
Age Based Pap/HPV Testing Non-Age Based Pap/HPV Testing
Under 30 (Cytology only – no HPV orders) Pap Only Pap and HPV Co-Testing w/ reflex Pap w/ reflex to HPV if ASC-US & above
30-65 (HPV co-testing with reflex to genotyping if HPV only to genotyping if Pap neg/HPV Pos HPV only w/ reflex to genotyping if positive
Pap Negative /HPV Positive) Pap & HPV Co-Test Pap w/ reflex to HPV if ASC-US Other: Conventional Pap
VIROLOGY TESTING Specimen Source Vagina (Swab) Cervix (Swab)
GC/Chlamydia Chlamydia Trachomatis Neisseria Gonorrhoeae (GC) Trichomoniasis (Required): (if not ThinPrep Vial) Urethra (Swab) Urine
NON-GYN CYTOLOGY SPECIMENS
LUNG BODY CAVITIES URINE SPECIMENS CENTRAL NERVOUS SYSTEM
Sputum Pleural Fluid Source: Voided Catheterized (CSF) Cerebrospinal Fluid
Bronchial Brush, Site: Pericardial Fluid Bladder Wash Shunt
Bronchial Wash, Site: Abdominal Fluid Cytology Only
MISCELLANEOUS SITE
Bronchoalveolar Lavage (BAL) Pelvic Wash
Other:
(GMS) Grocott Methenamine Silver Stain for Fungus and PCP Cancer Testing by UroVysion FISHTM
Other Stains: Bladder Cancer Testing by UroVysion FISH™

FINE NEEDLE ASPIRATION (FNA) SPECIMENS

Site A: ________________________ Left Right Site B: ________________________ Left Right Site C: ______________________ Left Right
Air Dried Smears (qty): ______________________ Air Dried Smears (qty): ______________________ Air Dried Smears (qty): ______________________
Fixed Smears (qty): ________________________ Fixed Smears (qty): ________________________ Fixed Smears (qty): ________________________
Other material (specify): _____________________ Other material (specify): _____________________ Other material (specify): _____________________

CLINICAL HISTORY:

Revised 8/20
 A. Notifier:
B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Non-coverage

(ABN)
NOTE: If Medicare doesn’t pay for D. below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have
good reason to think you need. We expect Medicare may not pay for the D. below.
D. E. Reason Medicare May Not Pay: F. Estimated
Cost

WHAT YOU NEED TO DO NOW:

 Read this notice, so you can make an informed decision about your care.
 Ask us any questions that you may have after you finish reading.
 Choose an option below about whether to receive the D. listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance
that you might have, but Medicare cannot require us to do this.
G. OPTIONS: Check only one box. We cannot choose a box for you.
□ OPTION 1. I want the D. listed above. You may ask to be paid now, but I
also want Medicare billed for an official decision on payment, which is sent to me on a Medicare
Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for
payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare
does pay, you will refund any payments I made to you, less co-pays or deductibles.
□ OPTION 2. I want the D. listed above, but do not bill Medicare. You may
ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
□ OPTION 3. I don’t want the D. listed above. I understand with this choice I
am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on
this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
I. Signature: J. Date:

CMS does not discriminate in its programs and activities. To request this publication in an
alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If
you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 06/30/2023) Form Approved OMB No. 0938-0566