PDF Test Requisition Form (TRF) Instructions

 PDF Test Requisition Form (TRF) Instructions
HOW
TO
USE
THE
C O R U S ® CAD PDF TRF
1. Download and Save the PDF TRF from the Web:
• Download the PDF TRF from our website:
o www.cardiodx.com/trf
o portal.cardiodx.com
• Save by right-clicking the ‘Download the Corus CAD PDF TRF’ link and select ‘Save Link As’ or
‘Download Linked File As’.
2. Open and Fill-out the PDF TRF:
• Open the PDF TRF using Adobe® Reader.
Note: A free version of Adobe Reader may be downloaded at http://get.adobe.com/reader/.
• Fill-out the PDF TRF fields electronically (see below for further details on the information required
on the TRF).
o All fields in RED must be completed prior to printing the document.
o Click on the boxes to select appropriate ICD-9 codes.
Note: The ICD-9 code boxes will be cleared when the PDF TRF file is saved after
downloading.
3. Print and Complete the PDF TRF:
• Upon completion of the required fields (in RED), and any other fields as appropriate, the PDF
TRF can be printed.
Note: A warning dialog box will appear if printing is attempted prior to completion of required
fields (in RED).
• Print two copies of the PDF TRF – one copy for inclusion with the Corus CAD test sample and
one copy for the patient record.
• Complete any remaining fields in Sections 1-5 on the printed TRF prior to submission of the test
sample (see below for further details on the information required on the TRF).
Note: The “Date Sample Taken” field must be filled out by the phlebotomist at the time of the
sample draw and the clinician must sign the printed TRF.
• Confirm all required fields in Sections 1-5 of the TRF are complete before sending the TRF
to CardioDx®.
• Confirm that the Clinician signature is present before sending the TRF to CardioDx.
• Attach a barcode label from the Corus CAD Sample Collection Label sheet to the completed
TRF.
• Place the completed TRF inside the Corus CAD Sample Collection Kit, along with the patient
sample.
Reference Instructions for: GXP-000663 Rev.1 Corus CAD - PDF Test Requisition Form
1
HOW
TO
C O M P L E T E S E C T IO N S 1-6
OF THE
C O R U S ® CAD PDF TRF
1. Account Information
Enter clinic contact information. A portion of the fields may be pre-filled and saved as a practice specific template.
If so, verify that they are correct.
2. Patient Information
Enter the patient name, date of birth and sex at birth. This information is required to perform the Corus CAD test.
A separate page containing all of the required patient demographics may be provided in lieu of completing this
section of the form, but the patient's name MUST be on the Test Requisition Form. Patient address is necessary
for billing reasons. The test should be used in adult patients only. Entering your clinic's Medical Record/ Patient
Number for the patient is optional and for your records only.
3. Billing Information
Diagnosis: The ICD-9 diagnosis codes must be defined to the highest level of specificity available and should
reflect codes documented in the patient’s medical record. The ICD-9 codes shown are listed as a convenience for
the ordering clinician. Clinicians are not required to use these ICD-9 codes.
Method of Payment: Check the box indicating the party responsible for payment of the test. If applicable, please
provide a clear copy of the front and back of the patient’s primary and any secondary
insurance/Medicare/Medicaid/other payer card. CardioDx® will submit claims to all private and government
insurance for insured patients.
For Patients Outside of Payer Coverage: CardioDx will contact your office to coordinate obtaining a signed
ABN (for Medicare patients) or written authorization (for patients with other insurance).
4. Blood Draw Information — to be completed by phlebotomist
Indicate the date that the blood draw occurred. Also, write in the phlebotomist's name, phlebotomy lab name and
phlebotomy lab phone number. The person conducting the blood draw must complete this section.
5. Clinician — to be completed by authorized clinician only
Enter clinician name. An authorized clinician MUST sign his or her name on the Test Requisition Form and
indicate the date the test is ordered.
6. Comments
Provide any comments for the CardioDx Commercial Laboratory staff in this section.
HOW
TO
O R D E R C O R U S CAD S A M P L E C O L L E C T IO N L A B E L S (B A R C O D E S )
To order the Corus CAD Sample Collection Labels (barcodes) contact CardioDx Customer Service at
1.866.941.4996, option 2. Unless rush service is specified, orders take 1–2 weeks to arrive.
HOW
•
•
TO
CREATE
A
P R A C T IC E S P E C IF IC PDF TRF T E M P L A T E
The Account Information (in section 1), the Phlebotomist Name/Contact Information (in section 4)
and the Clinician Name fields (in section 5) can be completed once and saved for continued use
as a practice specific template.
The Clinician Name field can accommodate multiple names for all clinicians in a practice (i.e. all
have the same Account Information) for ease of use as a practice specific template.
o Fill in all clinician names in the Clinician Name field once, re-name and save the PDF TRF
file.
o Mark the box next to the appropriate ordering Clinician’s name for each test order created
using the practice specific template. Reference Instructions for: GXP-000663 Rev.1 Corus CAD - PDF Test Requisition Form
2