Online Physician Service Order Form and Instructions


 

Online Order Form:

Note: LYKOS Service is not currently available, expected Q2 2018

 
last, first
Please identify the service you would like from the menu below.
Patient Name *
Patient Name
Date of Birth
Date of Birth
Required if "Other" selected above, or a more specific diagnosis is to be considered
Patient Sex *
The report number from the primary molecular report lab
Adding ethnicity is not required, but can result in more specific allelic frequencies in NGS reporting
Only needed for Lykos ngS service
Discharge Date
Discharge Date
Only needed for Lykos NGS service
Must match the submitted documents
Must match submitted documents. Please include the surgical pathology number AND the block number of the specimen.
Patient Address *
Patient Address
Insured Date of Birth
Insured Date of Birth
Please let us where the specimen is located in case there are delays in submission
please add any specific questions or concerns you may have about the patient, or any other relevant information we need to consider

Service order instructions:

Please register prior to submitting physician services.

  • For Client Bill Services (Case consults, data analyses) complete the form to the left
  • Obtain a copy of the existing molecular report, surgical pathology report, and a recent clinic note; upload these as attachments in an email to customerservice@bwpgprecisionmed.com
    • please note, additional files may also be requested if necessary, such as radiology reports and/or images
  • Order Authorization
    • This is an order for clinical services.  By adding your unique physician order ID you certify that:
      • The services are medically indicated and necessary to assist in patient care; and you may provide BWPG or third party payers patient medical records demonstrating medical necessity;
      • You have provided the patient with information regarding these services and have received the patient's consent for services to be provided by BWPG
  • Expected turn-around time for non-NGS services is three working days from delivery of all required materials

 

For the Lykos NGS service

  • Prior to ordering Lykos NGS services:
    • Print out Patient Authorization form and consent the patient
    • Please pre-authorize the patient for coverage to insurer
  • Acquire samples for testing from pathology laboratory
    • If you need assistance acquiring the specimens, please provide contact information for the lab holding the specimen in the online order form
    • The specifications for the sample will depend on the partner lab criteria.  In general, 10 unstained slides plus 1 H&E-stained slides are sufficient 
    • Send the specimen to the lab depending on the chosen lab partner.
  • Acquire the surgical pathology report and a recent clinic note for the submitted sample and send a copy to customerservice@bwpgprecisionmed.com , along with the patient authorization form. Please add the patient name and your physician ID in the subject header
    • We will hold the case for all relevant information unless you specify in the form to begin testing without these materials
  • Fill out the form to the right and submit
  • Order Authorization
    • This is an order for clinical services.  By adding your unique physician order ID you certify that:
      • The services are medically indicated and necessary to assist in patient care; and you may provide BWPG or third party payers patient medical records demonstrating medical necessity;
      • You have provided the patient with information regarding these services and have received the patient's consent for services to be provided by BWPG and the partner lab, and to release of results and relevant medical information necessary for billing to third party payers as part of the reimbursement process

 

  • Expected turn-around-time from receipt of all materials is 2 weeks

Please submit completed form to customerservice@bwpgprecisionmed.com

 

 

Note on patient data security

BWPG uses HIPAA-compliant data services and servers.  Please contact us with any security-related questions.