Tempus|nP Requisition Form

TEMPUS REQUISITION FORM

Neurology & Psychiatry
Please complete the fields below to order the Tempus|nP test for your patient. All fields with an asterisk (*) are required to begin processing your order. If you have any questions, please reach out to help@tempus.com or (312) 598-9961 for assistance.
ORDERING PROVIDER INFORMATION
Office / Practice / Institution Name*
Clinic Name (if applicable)
Ordering Provider*
Full Name
NPI
NPI
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
Required for report delivery and to receive a copy of this order form for your records.
PATIENT INFORMATION
Patient Full Name*

First NameLast Name
Medical Record Number
Date of Birth*

MonthDayYear
Sex*

MaleFemaleNot Specified
Gender
Race/Ethnicity
Patient Email Address*
Patient Phone Number*
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
SAMPLE COLLECTION INFORMATION
How is the sample being collected?*

Please ship a kit to the patient's address provided aboveThe sample was collected at the clinicThe patient took a kit home to complete
Please remind the patient that a kit will be delivered tomorrow and to promptly send the sample back to Tempus so we can process results in a timely manner.
Date of sample collection (if collected in office)

MonthDayYear
Date
If the sample was collected at the clinic, please let us know if you would like Tempus to schedule a FedEx pickup by listing your preferred time below. Tempus will email you to confirm the time frame scheduled.
Yes, we would like a FedEx PickUp scheduled at or before
CLINICAL INFORMATION
The listed ICD-10 codes are not all-inclusive. If a diagnosis other than those listed below supports the medical necessity of the service, select "Other" and enter the corresponding ICD-10 code below. The ultimate responsibility for correct coding belongs to the ordering clinician.
Diagnosis*
Date of diagnosis

MonthDayYear
Date
Additional Diagnosis
Please add additional diagnoses if not present in the list above. If you selected "Other" above, please specify the diagnosis.
Please list medications under consideration for the patient
Considered Medications: Medications under consideration for this patient*
Prior Medications: Medications previously taken by this patient*
Current Medications: Medications this patient is currently taking*
Clinical Document Upload

Patient Summary, Progress Note, Medication List, or other clinical documents
Cancelof
Current Medications
Prior Medications
Clinical Evaluations
Additional Clinical Information
Please add any relevant clinical notes
BILLING INFORMATION
Medical Justification (check at least one)*

Patient is a candidate for a pharmacogenomic test based on their diagnosis, medical history, medications they are currently taking, and/or based on medications they are being considered forPatient has failed at least one prior medication to treat their conditionPatient has never received a pharmacogenomic test to guide treatment for various psychotropic medicationsA medication with a clinically actionable pharmacogenomic implication is being considered for treatment of the patient’s psychiatric condition
Please list medications under consideration for the patient*
Bill Type*

Self Pay ($295)Insurance (must attach copy of card)Direct clinic billing
Patient Status (required for Medicare patients)

InpatientOutpatient
Date of discharge:

MonthDayYear
Date
Copy of Insurance Card

Please upload a copy of the patient's insurance card (front & back). If you do not have the patient's insurance information on file, we will reach out to the patient directly.
Cancelof

Click here to provide insurance information (if no card is uploaded)
Primary Insurance
Policy #
Group #
Policy Holder Name
Policy Holder DOB
Patient Relationship to Policy Holder

SelfSpouseChildOther

Billing Information: Collapse Stopper (should not be visible)
PROVIDER SIGNATURE

I certify that the patient has received an explanation of the purpose, risks, and benefits of the ordered test(s). My signature below certifies medical necessity of the test(s) (including that the test results will inform the treatment plan) and that the patient has provided informed consent that meets the requirements of applicable law for Tempus or its reference lab to: (a) collect and use the patient's samples (including genetic material) and health information and perform the ordered test(s); (b) obtain, receive, and release health information (including test results) as necessary for reimbursement or the processing of insurance claims; (c) retain and use samples and health information for an indefinite period of time in accordance with applicable law; and (d) de-identify such samples and information and use and share the resulting de-identified samples and information in accordance with applicable law.
Sign below*

Clear
Date of signature*

MonthDayYear
Date
Form completed by*
Please type the name of the individual who completed this form
Email
example@example.com
Should be Empty:

TEMPUS REQUISITION FORM

ORDERING PROVIDER INFORMATION

PATIENT INFORMATION

SAMPLE COLLECTION INFORMATION

CLINICAL INFORMATION

BILLING INFORMATION

PROVIDER SIGNATURE