Anatomic Pathology Service Request Forms
Reference Lab Service Request Policies
Anyone submitting specimens to the Department of Laboratory Medicine & Pathology for reference services is expected and considered to have read, and to agree to comply with, the following policies:
Compliance with the Law. The Department of Pathology (“Pathology”) agrees to perform its obligations related to reference services (“Services”) in accordance with all applicable federal, state and local laws and regulations, and expects any client submitting a specimen to its laboratories to do the same. These laws include, but are not limited to, all laws, regulations and requirements applicable to physicians, reference laboratories, Medicare and Medicaid participants, and healthcare providers in general. These Terms and Conditions shall be construed in a manner consistent with compliance with such statutes and regulations. The unenforceability or invalidity of any provision of these Terms and Conditions shall not affect the validity and enforceability of the remainder of the provisions, unless such unenforceability or invalidity would materially change the parties’ relationship and obligations.
Supplies. Pathology will furnish as needed, mailing containers, special specimen collection containers, special fixatives and request forms required for the collection and transportation of specimens for Services to Pathology.
Requests for Services. All requests for Services must be submitted to Pathology on a Pathology Reference Laboratory Service Request form. Specimens must be properly prepared and packaged for shipment or transport, as applicable, in accordance with all federal, state, and local laws.
- Slide Review and Consult Request Form (slides, blocks, and some* tissue) for the following diagnostic services (links go to service page):
- General Consults / Reviews
- Breast & Gynecological Pathology
- Bone & Soft Tissue
- Cardiac Tissue *
- Cytology and Cervical
- Electron Microscopy (EM)
- Gastrointestinal (GI) Pathology
- Genitourinary (GU) Pathology
- Immunohistochemistry (IHC) and Immunofluoresence (IF)
- Additional Forms Required:
Non-slides or blocks: IHC Service Request Form
Slides, blocks or renal vials: General Slide Review and Consult Request Form (linked above)
- Additional Forms Required:
- Renal Pathology *
- Neuropathology Service Form
- Neuropathology [only] Slides, Block, and Tissue Service Form
- Cytogenetics and Genomics Test Request Forms
- DNA Flow Cytometry Service Request Form
- IHC & Molecular Service Form (see also Renal Biopsy)
- Cytology & Molecular Service Form (non slides or blocks)
Fees. Clients shall pay Pathology according to the applicable fee schedule, which will be provided to Client.The rate for diagnostic pathology services is intended to reflect fair market value for such services. The rate is not intended to, and does not, represent an inducement or reward for referrals for health care items or service. For Services provided by Pathology to Clients, Clients shall be responsible for billing third party payors or patients for all tests it sends to Pathology. Pathology shall in no event bill any other source for Services requested by and provided to Clients.
Invoices. Upon mutual agreement, Pathology may send Clients individual invoices or an invoice summarizing Services furnished in each calendar month. Clients shall pay Pathology no later than 30 days following receipt of any invoice.
Canceled Service Orders. Client may cancel an order for Services by calling Pathology at 206.598.6400 prior to completion of testing. If a Client calls Pathology prior to completion of testing, Client will not be charged for the test. If a Client calls Pathology after completion of testing, Client will be charged for the test.
Unacceptable Specimens and Unsatisfactory Results. If Pathology cannot analyze specimens because of improper collection or degradation in transit, Pathology will promptly notify Client and not charge Client. If Pathology is unable to obtain satisfactory test results because of inadequate specimen or sample, Pathology will promptly notify Client.
Confidentiality. Pathology and Clients agree to abide by all federal and relevant state law with respect to maintaining the confidentiality of patient information. In particular, Pathology and Clients agree:
- To comply with the applicable provisions of the Administrative Simplification section of the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. § 1320d through d-8, and the requirements of all related regulations (“HIPAA”);
- Not to use or further disclose any individually identifiable health information or protected health information (“PHI”), as those terms are defined in HIPAA, concerning a patient other than as permitted by HIPAA and relevant state law;
- To promptly report to the other party any use or disclosure of a patient’s PHI related to a specimen submitted to Pathology that is in violation of HIPAA or state law, of which the reporting party becomes aware;
- To make their internal practices, books, and records related to the use and disclosure of PHI available to the Secretary of Health and Human Services to the extent required for determining compliance with HIPAA. Clients are responsible for obtaining all necessary and legally required authorizations from their patients for the release of medical information by Pathology in its performance of reference lab services. Clients will provide such patient authorization to Pathology upon request.
Insurance. The University of Washington provides professional liability coverage to Pathology through a self-insurance program pursuant to RCW 28B.20.250 through RCW 28B.20.255, which is equivalent to or exceeds limits of at least $1,000,000 per occurrence/claim and $3,000,000 annual aggregate. Clients are expected to carry current and ongoing professional liability insurance with limits of at least $1,000,000 per occurrence/claim and $3,000,000 annual aggregate.
Indemnification. Pathology and Clients each agree to indemnify and hold each other harmless from any and all costs, expenses, liability, loss, claims, or damages incurred as a result of their own negligent acts or omissions in connection with reference lab services, or the negligent acts or omissions of their employees, officers, and agents.
No Obligation to Make Referrals. None of the benefits to either Pathology or Clients as a result of reference lab services is conditioned on any requirement that either party make or influence referrals to, or otherwise generate business for, the other party.
Access to Records. To the extent required by law, at the expiration of six years after the furnishing of any reference lab services, Pathology and Clients will make available, upon request by the Secretary of the U.S. Department of Health & Human Services, the Comptroller General, or any of their duly authorized representatives, the contracts, books, documents and records that are necessary to certify the nature and extent of all Medicare costs with respect to such services. If Pathology carries out any duties related to reference lab services through a subcontract with a value or cost of $10,000 or more over a twelve-month period, such subcontract shall contain a clause to this effect.
Independent Contractors. Pathology and Clients are independent contractors as to each other, and neither party, nor any agent, employee, or representative of either party shall be deemed to be an employee of the other. Provision of reference lab services shall not be construed to create any partnership, joint venture, lease or equity relationship, expressly or by implication, between the parties, and Clients will not make any adjustments to amount to be paid to Pathology for employee taxes, including federal and state income taxes, FICA, FUTA, and earnings taxes. Each party shall have sole responsibility for the reporting and payment of these taxes for its own respective employees.
Non-Excluded Providers. Pathology and Clients each certify that neither it nor any of its employees performing services related to reference lab services has been debarred, suspended, declared ineligible, or excluded from Medicare/Medicaid or any other federal or state healthcare program. Each party shall promptly notify the other of any limitation or governmental action initiated against it that would materially affect the provision of reference lab services.
Governing Law and Venue. Resolution of any disputes between Clients and Pathology regarding reference lab services shall be construed in accordance with the laws of the State of Washington. Venue shall be in King County.
Negotiation. Clients and Pathology agree to negotiate in good faith any dispute regarding reference lab services before proceeding to other remedies, such as mediation, arbitration or legal proceedings.
Reference Service Request Forms
Service request forms for UW Medicine Pathology clinical reference services located at Harborview Medical Center (HMC) and the University of Washington Medical Center are provided at the following website links:
HMC offers services in Anatomic Pathology, Neuropathology, Histology and Cytology and UWMC offers a variety of services in Cardiac, Dermatopathology, Electron Microscopy, Flow Cytometry, IHC, Renal and Histology.