Download PGX TEST REQUEST FORM

AFFIX SPECIMEN
BARCODE HERE
PGX TEST REQUEST FORM
PATIENT INFORMATION (required)
INSTRUCTIONS
1.
2.
Date:
/
/
Time of collection
:
Source:
Buccal Swab
Please PRINT CLEARLY when providing required information to ensure proper processing.
Provide all primary/secondary insurance information from the EMR and attach copies of patient insurance cards and photo ID (front and back).
PATIENT INFORMATION (required)
LASTNAME
MIDDLE INITIAL
FIRSTNAME
CITY
STREETADDRESS
PREFERRED CONTACTPHONE NO.
STATE
THIS ISA
□ Home
DATE OFBIRTH
ZIPCODE
GENDER
□ Mobile
□ Work
□ Male
□ Female
RACE/ETHNIC IDENTIFICATION
□ African American
□ Jewish - Ashkenazi
□ Asian
□ Jewish - Sephardic
□ Caucasian
□ Native American
PATIENT INSURANCE INFO RMATION (required)
*Self Pay please provide patient email and phone number for Pay Pal Invoice.
Please include a photocopy of insurance card(s) (front and back).
PLEASE SELECT A BILLING OPTION & COMPLETE THE INFORMATION BELOW:
□ Medicare
□ Medicaid
□ Hispanic
□ Other:
□ Insurance
□ Self Pay
PRIMARY INSURANCE CARRIER
SECONDARY INSURANCE CARRIER
PATIENT RELATIONSHIP TO INSURED
□ Self
*□ Self Pay
□ Spouse
□ Dependent
□ Other
□ Patient Phone No.:
□ Patient Email:
MEDICAL NECESSITY (required; check all applicable)
PATIENT MEDICAL INFORMATION(required)
Please choose any panel that is supported by medical necessity.
Attach a photocopy of demographic sheet, medication list and the portion of the
medical record that supports medical necessity.
□ Medication Therapy Management Requested
□ CYP 2D6 – By checking this box you are indicating that the above patient’s
gene testing is used to guide medical treatment/dosing or considering
medications for individual’s therapy with tricyclics
□ CYP 2C19 – By checking this box you are indicating that the above patient’s
gene testing is used toguide medical treatment/dosing or consider medications
for individual’s therapy with Clopidogrel or a similar drug.
□
□
□
□
Drug intolerance & side effects – observed
Drug intolerance & side effects – family history
Treatment–multiple medications
Treatment–FDA-cleared drug w/genetic
guidance
□ Vulnerable patient – elderly or infirm
□ Vulnerable patient – child or adolescent
□ Treatment – medical devices (e.g. stents)
□ Treatment – resistance and/or lack of
efficacy
PATIENT HISTORY / REASON FOR ORDERING TESTS / COMMENTS
CURRENT MEDICATIONS
CONSIDERED MEDICATIONS
PANEL OPTIONS (required)
For Lab use only:
□ Comprehensive Panel (incl. CYP 2C9, 2C19, 2D6, 3A4, 3A5, VKORC1, FII, F V, M
THFR, SLCO1B1) - includes more than 95% of medications
□ Limited Panel (incl. CYP 2C9, 2C19, 3A4, 3A5, VKORC1, FII, FV, MTHFR, SLCO1B1) includes less than 75% of medications, excludes opioids, antidepressants, beta
blockers and anti-psychotics
□
PRACTICE/CLINIC INFORMATION (required)
PHYSICIAN NPI NUMBER
PRACTICE/CLINIC NAME
PHYSICIAN AUTHORIZATION / ICD-10 CODE(S) (required)
ENTER ICD-10 CODE(S) BELOW OR SELECT ON BACK
PRACTICE/CLINIC ADDRESS
PHONE NO.
EMAIL ADDRESS
PHYSICIAN NAME
PHYSICIAN SIGNATURE
PATIENT CONSENT
REIMBURSEMENT: CQuentia (CQ) will make every reasonable effort to obtain reimbursement for the ordered tests above. I hereby authorize CQ to release to Medicare and/or
any insurance carrier providing medical benefits to me and any health plan to which I am a member any and all medical or other information necessary for claims purposes. I hereby
authorize payment of medical insurance benefits to the party who bills for these claims and accepts assignments. I understand that if my insurance company pays me directly for the services
provided by CQ that I am responsible for forwarding such payment to CQ. I understand that I am responsible for any outstanding balances, deductible/co-payments as required by my plan.
INFORMED CONSENT OF GENETIC INFORMATION: I consent to having genetic analysis performed and the results of the analysis made available to my physician (where requested). All
claims to the samples and genetic information are released to CQ. This signed test request form authorizes CQ, and its assigns, to utilize the sample(s) for further research following
HIPAA-compliant de-identification of the samples.
PATIENT NAME (please print)
PGx Test Request Form
FM-80009-L
11/16
PATIENT SIGNATURE
817.882.6900
www.cquentia.com
COLLECTION DATE
PRINT COLLECTOR’S NAME HERE
CQuentia
CLIA No.: 11D2074759
NPINo: 1124442306
NOTE: For the convenience of the ordering physicians, the below IDC-10 codes are listed.
Physicians are not required to use these codes but should report the diagnostic code(s) that
best describes the reason for performing the test.
CYP2D6 DIAGNOSIS ICD-10 CODES
SECTION

ICD-10
Mental
Mental
Mental
Mental
Mental
Mental
F31.30
F31.32
F31.4
F31.5
F31.60
F31.64
Mental
Mental
Mental
Mental
F31.75
F31.76
F31.77
F31.78
Mental
Mental
Mental
Mental
F33.0
F33.3
F33.40
F33.42
CYP2C19 DIAGNOSIS ICD-10 CODES
DESCRIPTION
Bipolar Disorder, Current Episode
Depressed, mild or moderate severity, unspecified
Depressed, moderate
Depressed, severe, without psychotic features
Depressed, severe, with psychotic features
Mixed, unspecified
Mixed, severe, with psychotic features
Bipolar Disorder
In partial remission, most recent episode depressed
In full remission, most recent episode depressed
In partial remission, most recent episode mixed
In full remission, most recent episode mixed
MDD
Recurrent, mild
Recurrent, severe, with psychotic symptoms
Recurrent, in remission, unspecified
Recurrent, in full remission
Atherosclerotic Heart Disease of Native Coronary Artery
Without angina pectoris
With unstable angina pectoris
With angina pectoris with documented spasm
With other forms of angina pectoris
Ischemic cardiomyopathy
Silent myocardial ischemia
Atherosclerosis of Autologous Artery Coronary Artery
Bypass Grafts(s)
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
I25.10
I25.110
I25.111
I25.118
I25.5
I25.6
Circulatory
Circulatory
Circulatory
I25.720 With unstable angina pectoris
I25.721 With angina pectoris with documented spasm
I25.728 With other forms angina pectoris
Atherosclerosis of Bypass Graft of Coronary Artery of
Transplanted Heart
I25.760 With unstable angina
I25.761 With angina pectoris with documented spasm
I25.768 With other forms of angina pectoris
Atherosclerosis of Other Coronary Artery Bypass
Graft(s)
I25.790 With unstable angina pectoris
I25.791 With angina pectoris with documented spasm
I25.798 With other forms of angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s)
without angina pectoris
I25.812 Atherosclerosis of bypass graft of coronary artery of
transplanted heart without angina pectoris
I25.83 Coronary atherosclerosis due to lipid rich plaque
I25.84 Coronary atherosclerosis due to calcified coronary lesion
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
Circulatory
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
Cerebral Infarction Due to Unspecified Occlusion or
Stenosis
I63.511 Of right middle cerebral artery
I63.512 Of left middle cerebral artery
I63.519 Of unspecified middle cerebral artery
I63.59 Of other cerebral artery
Occlusion and Stenosis
I66.01
I66.02
I66.03
I66.8
Z79.02
Of right middle cerebral artery
Of left middle cerebral artery
Of bilateral middle cerebral arteries
Of other cerebral arteries
Long term (current) use of antithrombotics/antiplatelets
NOTE: All CYP2C19 Diagnosis ICD-10 Codes listed above
must be reported with a secondary diagnosis of Z79.02
DIAGNOSIS ICD-10 CODES (For all assays except CYP2D6 and CYP2C19)
Digestive
Endocrine,Metabolic
Endocrine,Metabolic
Endocrine,Metabolic
Musculoskeletal
Musculoskeletal
Musculoskeletal
Musculoskeletal
Musculoskeletal
Musculoskeletal
Musculoskeletal
Nervous System
Signs & Symptoms
Signs & Symptoms
Signs & Symptoms
Signs & Symptoms
PGx Test Request Form
FM-80009-L
11/16
K21.
E03.
E11.
E10.
M60.9
M79.7
M19.9
M79.609
M54.15
M54.16
M54.17
G43.909
R53.1
R51
R06.02
R11.2
Gastroesophageal reflux, no esophagitis
Hypothyroidism,unspecified
Diabetes II mellitus, without complications
Diabetes I mellitus, without complications
Myositis, unspecified
Fibromyalgia
Osteoarthritis, unspecified, unspecified site
Pain in unspecified limb
Radiculopathy,thoracolumbar region
Radiculopathy, lumbar region
Radiculopathy,lumbosacral region
Migraine, unspecified, not intractable, without status
Weakness
Headache
Shortness of breath
Nausea w vomiting, unspecified
CQuentia
CLIA No: 11D2074759
NPI No: 1124442306