Knoxville Dermatopathology Laboratory
Paul B. Googe, M.D., P.C., Laboratory Director
315 Erin Drive
Knoxville, Tennessee 37919
Telephone 865-584-1933
Fax 865-584-1323
Toll Free 1-800-772-0951
www.labpath.com
Requisition No. -

BILL DOCTOR

BILL PATIENT / INSURANCE
INCLUDE OR ATTACH ALL BILLING INFO

CHART NO.
DATE COLLECTED
TIME COLLECTED
PHYSICIAN
ICD 9 CODE
PATIENT NAME (LAST, FIRST, MIDDLE)
S.S. NO.
DOB
SEX
PATIENT ADDRESS (INCLUDE APT. NO.)
STATE
CITY
ZIP
PHONE NO.
RESPONSIBLE PARTY (IF OTHER THAN PATIENT)
SS # OF RESPONSIBLE PARTY
EMPLOYER OF RESP. PARTY
INSURANCE NAME
INSURANCE ADDRESS (INCLUDE CITY, STATE, ZIP CODE)
GROUP NO.
POLICY NO.
MEDICARE NO.
TENNCARE NAME AND ID NO.
CLINICAL HISTORY AND PHYSICAL FINDINGS
SPECIMEN SITE
CLINICAL DIAGNOSIS
SPECIAL REQUESTS






















































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