Tempus Lung Cancer NGS Program Requisition Form
This requisition form is designed for patients with advanced or metastatic NSCLC to participate in the Lilly Lung Cancer NGS Program. Completing the form ensures eligibility for no-cost genomic variant testing. It is essential for healthcare providers and patients to understand all requirements for proper submission.
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How do I fill this out?
To fill out this requisition form, gather all the necessary patient and physician information. Ensure that all eligibility criteria are met before submission. Once completed, review the form for accuracy before sending it to Tempus.
How to fill out the Tempus Lung Cancer NGS Program Requisition Form?
1
Collect required patient information like name, DOB, and medical record.
2
Fill in the ordering physician's details including contact and facility information.
3
Select necessary testing options as per the patient's eligibility.
4
Provide specimen retrieval details for accurate processing.
5
Sign and date the form to certify completion and consent.
Who needs the Tempus Lung Cancer NGS Program Requisition Form?
1
Oncologists who need to refer patients for genomic testing.
2
Patients with advanced NSCLC seeking new treatment options.
3
Healthcare providers managing patient care plans.
4
Research institutions gathering data on lung cancer mutations.
5
Insurance companies for coverage verification of testing.
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What are the instructions for submitting this form?
For submitting the form, you can either fax it to Tempus at 800.893.0276 or email it to support@tempus.com. Ensure that the completed form includes all necessary signatures and information pertinent to the patient's eligibility. Additionally, physical submissions can be mailed to Tempus at 600 West Chicago Avenue, Suite 510, Chicago, IL 60654.
What are the important dates for this form in 2024 and 2025?
Keep in mind important deadlines for submission may vary by year. For 2024 and 2025, please refer to the latest communication from Tempus or consult the healthcare provider for the most accurate dates.
What is the purpose of this form?
The purpose of this form is to facilitate the enrollment of eligible patients into the Lilly Lung Cancer NGS Program. This program provides advanced genomic testing to patients with metastatic NSCLC at no cost. It is crucial for gathering necessary patient information to support tailored treatment decisions based on genomic findings.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name: Patient's last name.
- 2. DOB: Patient's date of birth required for identification.
- 3. Medical Record #: Unique identifier for patient records.
- 4. Biological Sex: Indicates whether patient is male or female.
- 5. Address: Complete address of the patient.
- 6. Ordering Physician: Full legal name of the physician ordering the tests.
- 7. Contact Information: Includes physician's email, phone, and facility details.
- 8. Tests Ordered: Specifies the type of genetic tests required.
- 9. Specimen Retrieval: Details on how specimens will be collected.
- 10. Consent Signature: Signature confirming patient consent for genetic testing.
What happens if I fail to submit this form?
If this form is not submitted correctly, there may be delays in processing the patient's eligibility for genomic testing. Missing information can lead to the rejection of the requisition or the tests being billed to the patient. It is vital to review all fields before submission to avoid complications.
- Incomplete Information: Failing to provide all required fields may result in delays.
- Missing Signatures: Unsigned forms cannot be processed and will be returned.
- Incorrect Contact Details: Incorrect information may hinder communication regarding test results.
How do I know when to use this form?
- 1. Referral for Testing: Used by healthcare providers to initiate testing for patients.
- 2. Patient Enrollment: Enrolls eligible patients in the genomic testing program.
- 3. Specimen Submission: Facilitates the collection and submission of biological specimens.
Frequently Asked Questions
What is the purpose of this form?
This form allows patients with advanced NSCLC to apply for genomic testing through the Lilly Lung Cancer NGS Program.
Who can fill out this form?
The form can be filled out by healthcare providers on behalf of patients eligible for the testing.
What information is required on the form?
Necessary details include patient demographics, physician information, and testing options.
How do I submit the completed form?
The completed form can be submitted via fax or email to Tempus.
Can I edit this form online?
Yes, you can edit this form using PrintFriendly's PDF editor.
Is there a cost for the testing?
Eligible patients can receive the tests at no cost under this program.
What happens if I miss the deadline for submission?
Missing the deadline may delay the testing process and potentially affect treatment decisions.
Is consent required for the tests?
Yes, patient consent is mandatory prior to conducting any genetic tests.
How will my health information be used?
Your health information will be used only as permitted under applicable privacy regulations.
What if I have questions about filling out the form?
You can contact Tempus support for assistance with the form.
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