CAMD Forms/Requisitions

Institutional Account Request

• CPT Codes
• Medical Release
• Patient Information
• Payment Options
• New Provider Information Form (Providers new to Brigham and Women's Hospital)

Forms

• Cytogenetics Testing Consent Form
• Prenatal Microarray Consent Form

Requisitions

• Constitutional Cytogenetics Requisition
• Bone Marrow and Leukemic Blood Requisition
• Solid Tumor and Lymph Node Requisition
• Molecular Diagnostics Requisition

Members of Mass General Brigham Network:

• Patient's insurance will be billed for services.
• Please provide complete patient information with requisition.
• New providers please complete Provider Information Form

Non-members of Mass General Brigham Network:

• Please provide complete patient information with requisition.
• Institutions will be billed for services.
• Please provide institutional and provider information with requisition.

Please call the CAMD Department at 857-307-1500 for assistance.