PLEASE PRINT UNIVERSITY OF MEDICAL CENTER REQUEST FOR ANATOMIC PATHOLOGY CONSULTATION Patient Information - Complete All Fields Last Name First Name M.I. SSN

Street Address City State Zip

Bill Submitting Institution  Bill Patient*  DOB Sex Phone *Note: If payment is denied by the patient's insurance, you will be responsible for payment for services. Insurance Carrier Policy # Group # Name of Policy Holder and relationship to patient

Insurance Carrier Address City State Zip

Collection/Reporting Information – Complete all Fields Requesting Pathologist: Last Name First Name

Pathologist Phone # Fax Number

Institution Name & Address

Street City State Zip

Date Specimen Collected Institution Phone # Fax

Copy to: Physician Name Phone # Fax

Clinical History: ______

Pre-op Diagnosis ______Post-op Diagnosis ______Procedure ______

Specimen(s): Outside case #(s): ______

Prepared slides (#)*: ______Unstained Slides(#)**: ______Adhesive Used:______*Recut slides preferred to allow for retention by UPMC Faculty. **Blocks are preferred.

Blocks (#) & Description: ______Fixative: ______

Anatomic Pathology Consultation Request: Must check one for testing to occur. Attach original pathology report from your institution!  Complete formal consultation: Designated Pathologist (optional; see reverse side): ______ Immunoperoxidase stains only, no interpretation (mail to Presbyterian): ______ Immunoperoxidase stains with interpretation (mail to Presbyterian): ______ Special histochemical stains only (state individual stains; mail to Presbyterian):______ Special histochemical stains and interpretation (state individual stains; mail to Presbyterian): ______ Other, specify: ______ Molecular tests on solid tumors (See reverse side; mail to Presbyterian): ______

For Testing Use Only Secondary Patient Identification:______Demographics Sent? Yes  No  Requisition #______Date of Receipt:______Date forwarded to Pathologist (and tech initials)______All consultations should be mailed or sent by courier to (See reverse for pathologist location): UPMC – UPMC Shadyside Magee-Womens Hospital of UPMC UPMC Montefiore Presbyterian University Hospital Dept. of Pathology Dept. of Pathology Hospital Dept. of Pathology Consultation Services – Consultation Services - Department of Consultation Services – Room WG02 Room 4109 Transplantation Room C606 5230 Centre Avenue 300 Halket Street Consultation Services – 200 Lothrop Street Pittsburgh, PA 15232 Pittsburgh, PA 15213 Room E-733 Pittsburgh, PA 15213-2582 Telephone: 412-623-2318 Telephone: 412-641-4641 3459 Fifth Avenue Telephone: 412-647-8275 Fax: 412-682-6450 Fax: 412-641-6169 Pittsburgh, PA 15213 Fax: 412-647-0221 Telephone: 412-647-7645 UPMC Presbyterian Hospital Fax: 412-647-5237 UPMC St. Margaret UPMC Clinical Lab Building Dept. of Neuropathology Department of Pathology Department of Hematopathology Consultation Services – Consultation Services – Consultation Services – S701 Scaife 815 Freeport Road 9th Floor, Room 9032 3550 Terrace Street Pittsburgh, PA 15215 3477 Euler Way Pittsburgh, PA 15261 Telephone: 412-784-4130 Pittsburgh, PA 15213 T: 412-624-9415 Fax: 412-784-4985 Telephone: 412-864-6175 F: 412-624-5610 Fax: 412-864-1784

Rev. date – 6/14

AUTOPSY/INFECTIOUS ENDOCRINE PATHOLOGY INFORMATICS PATHOLOGY Yuri Nikiforov, MD, PhD Liron Pantanowitz, MD Jeffrey Nine, MD Robert Peel, MD UPMC Shadyside: UPMC Presbyterian: (412) 647-3936 Raja Seethala, MD (412) 623-1326 UPMC Presbyterian: (412) 647-9051 BONE-SOFT TISSUE KIDNEY/EM PATHOLOGY EYE PATHOLOGY Sheldon Bastacky, MD Alka Palekar, MD Charleen Chu, MD, PhD UPMC Presbyterian: (412) 647-9612 Uma N. M. Rao, MD UPMC Presbyterian: (412) 647-9417 UPMC Shadyside: AND TRANSPLANT (412) 623-2318 FISH STUDIES PATHOLOGY Karen Schoedel, MD Sanja Dacic, MD, PhD A. Jake Demetris, MD UPMC Presbyterian: UPMC Presbyterian: (412) 647-8694 Marta Minervini, MD (412) 647-9575 Michael Nalesnik, MD GENITOURINARY PATHOLOGY Parmjeet Randhawa, MD BREAST/GYNECOLOGIC PATHOLOGY Rajiv Dhir, MD UPMC Presbyterian: (412) 647-7645 AND GYN- CYTOPATHOLOGY UPMC Shadyside: (412) 623-2318 R. Marshall Austin, MD MALIGNANT MELANOMA Rohit Bhargava, MBBS Sheldon Bastacky, MD Uma N. M. Rao, MD Gloria J. Carter, MD UPMC Presbyterian: (412) 647-9612 UPMC Shadyside: Beth Clark, MD (412) 647-2319 David Dabbs, MD GI PATHOLOGY (See Dermatopathology) Esther Elishaev, MD Jon Davison, MD Jeffrey Fine, MD Douglas Hartman, MD MOLECULAR AND GENOMIC Mirka Jones, MD Shih-Fan Kuan, MD PATHOLOGY Amal Kanbour-Shakir,MD PhD Michael Landau, MD Yuri Nikiforov, MD, PhD Olga Navolotskaia MD Cathy Ma, MD, Ph.D Marina Nikiforova, MD Jing Yu, MD, PhD Reetesh Pai, MD Peter Lucas, MD Chengquan Zhao, MD Aatur Singhi, MD Somak Roy, MD UPMC Magee: (412) 641-4641 UPMC Presbyterian: (412) 647-3720 UPMC Presbyterian: (412) 802-6083

CARDIAC PATHOLOGY HEAD AND NECK PATHOLOGY NEUROPATHOLOGY Samuel A. Yousem, MD Simion Chiosea, MD Clayton Wiley, MD, PhD (412) 647-6193 Robert Peel, MD Charleen Chu, MD, PhD Raja Seethala, MD Ronald Hamilton, MD CYTOPATHOLOGY- UPMC Presbyterian: Julia Kofler, MD NON-GYNECOLOGICAL (412) 647-3732 Geoffrey Murdoch, MD, PhD N. Paul Ohori, MD UPMC Presbyterian: UPMC Presbyterian: (412) 647-3478 HEMATOPATHOLOGY (412) 647-9417 Steven H. Swerdlow, MD CYTOPATHOLOGY- Nidhi Aggarwal, MD PERINATAL PATHOLOGY NON-GYNECOLOGICAL Grant Bullock, MD, PhD Tony Parks, MD Sara Monaco, MD Lydia Contis, MD Trevor Macpherson, MD Liron Pantanowitz, MD Miroslav Djokic, MD UPMC Magee: (412) 641-3708 Juan Xing, MD Sarah Gibson, MD UPMC Shadyside: (412) 623-3765 UPMC Presbyterian: PULMONARY AND (412) 647-5191 MEDIASTINAL PATHOLOGY DERMATOPATHOLOGY/IF Samuel A. Yousem, MD Jagjit Singh, MD Sanja Dacic, MD, PhD Katherine Doeden, MD N. Paul Ohori, MD UPMC St. Margaret: (412) 784-4000 UPMC Presbyterian: 815 Freeport Road (412) 647-6193 Pittsburgh, PA 15215 TUMOR CYTOGENETICS Urvashi Surti, PhD UPMC Magee: (412) 641-4267