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2165 North Decatur Road | Decatur, Georgia 30033 855-831-7447 | 404-778-8499 Fax: 404-778-8559 Scan for full test menu COMPREHENSIVE BIOCHEMICAL GENETICS TEST REQUISITION FORM PATIENT INFORMATION Ethnicity (check all that apply) Last Name Street Address First Name MI Patient ID City DOB (mm/dd/yyyy) Sex ❍ State Zip Country F ❍ M ❍ ❍ Unknown ❏ ❏ ❏ ❏ ❏ ❏ African-American ❏ ❏ GENETIC COUNSELOR Asian Caucasian/NW European Hispanic ❏ ❏ E. Indian Jewish-Ashkenazi Jewish-Sephardic ❏ Mediterranean Native American Other Ambiguous Preferred Phone ORDERING ENTITY & REPORT DISTRIBUTION ❏ ❏ PHYSICIAN INSTITUTION Name Name Name Phone Phone Phone Fax (required to receive a copy of the report) Fax (required to receive a copy of the report) Fax (required to receive a copy of the report) Street Address Street Address Email Address City State Zip City Country State Zip Email Address Country Email Address NPI CLINICAL INFORMATION Please provide family history or other relevant information below. ICD-10 Codes Please check all of the following situations that apply: Patient has had transfusion within the past 30 days Patient has had bone marrow transplant Patient or family member is pregnant LMP/EDD Results will directly impact patient treatment Family history of genetic disease ❏ ❏ ❏ ❏ ❏ SPECIMEN INFORMATION LAB USE ONLY Date Collected (MM/DD/YYYY) Received ❍ AM ❍ Time Collected Sender Specimen ID TEMP RCF SAMPLE TYPE ❏ ❏ ❏ ❏ ❏ ❏ Whole Blood Skin Biopsy Serum Cult Fibroblast Plasma Other ❏ ❏ ❏ ❏ Unboxed by PM DBS Urine CSF Supernatant for Pyruvate SPECIMEN COLOR NO. TUBES COMP. PT. DATA RCF TEST DATA RCF PHYSICIAN DATA RCF BILLING DATA BILLING ❏ Facility Bill Acct. No. Hold Billing ❏ ❏ Reflex Self Pay Specimen Labeled by INCOMP. ❏ ❏ ❏ ❏ QC Insurance Bill Accessioned by ❏ ❏ ❏ ❏ Accessioning Label Comprehensive Biochemical Genetics Requisition Form | Generated 11-18-2016 22:29:55 | Page 1/4 Accessioning Label 2165 North Decatur Road | Decatur, Georgia 30033 855-831-7447 | 404-778-8499 Fax: 404-778-8559 Scan for full test menu COMPREHENSIVE BIOCHEMICAL GENETICS TEST REQUISITION FORM Patient Name: Last First MI Submit this completed payment options form with the specimen. Testing is not initiated until billing information is received. Billing policy is available at http://geneticslab.emory.edu/billing. INTERNATIONAL SAMPLES Payment in full must be made before samples will be processed. Prepaid samples receive a discount when section 3 is completed and signed with credit card information or a check is received with the sample. Please visit our website for more information: http://geneticslab.emory.edu/billing/international. Banker's checks or money orders must be made payable to Emory Genetics Laboratory. Please contact the EGL billing office for further arrangements or when you make an electronic fund payment at 404-778-8580 or [email protected]. PAYMENT OPTIONS (please fill out one of the following options) 1 - INSTITUTION To establish an institutional account, new clients must complete an Institutional Account Request Form prior to submitting an order. The form can be downloaded at http://geneticslab.emory.edu/billing. For any questions or to confirm whether you have an account or what your account number is, please contact the EGL billing office at 404-778-8580 or [email protected]. Institution Account Number The following information is not required if account number is provided above: Contact Name EGL Billing Label Please call to request labels Email Billing Address City State Phone Zip Fax 2 - INSURANCE (Also includes GA Medicaid, Wellcare, Amerigroup, Peachstate for GA Residents and Medicare). EGL does not accept non-Georgia Medicaid A legible copy of the front and back of the insurance card is required as well as any applicable insurance authorizations. A completed and signed Advance Beneficiary Notice of coverage (ABN) is required for Medicare patients. ICD-10 Diagnosis Code(s) *Required P R I M A R Y S E Policy Holder Name C O DOB N D Relationship to patient A ❍ Self ❍ Spouse R Y Policy Holder Name Gender ❍ Female ❍ Male DOB (mm/dd/yyyy) Relationship to patient ❍ Self ❍ Spouse ❍ Dependent ❍ Other Insurance Company Name Policy Number Group Number Address City Phone Gender ❍ Female ❍ Dependent Insurance Company Name Zip Other Address City Authorization No. (copy of auth. letter required) State Phone Male Policy Number Group Number State ❍ ❍ Zip Authorization No. (copy of auth. letter required) Authorization to assign benefits, accept financial responsibility, and disclose health records If I am entitled to benefits under the Medicare program, the Medicaid program, or any insurance policy or other health benefit plan, in consideration for services provided to me by EGL, I assign, transfer and convey the benefits payable under such program, policy or plan for such services to EGL. I authorize payment of benefits directly to EGL, with such benefits applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me and I agree to pay charges not paid under this assignment, including any coinsurance amounts and deductibles and any charges for services deemed to be non-covered, not pre-certified or not preauthorized by my insurance plan. I understand that EGL is permitted to disclose my health information for purposes of payment of bills (if I filled out section 2 above), my continued care or treatment, and healthcare operations. I authorize my physicians or any facility to release my health information to the Emory Genetics Laboratory for the purposes of payments of bills or claims. Signature of patient, parent, of Guardian (required) Date 3 - SELF PAY Payment Method ❍ Cashier Check Amount $ ❍ VISA Credit Card No. CVV MasterCard ❍ Discover Required for credit card payments Expiration Date Cardholder Printed Name as it Appears on Card Cardholder Billing Address City Zip ❍ (include discount if applicable) State Cardholder Signature Cardholder Phone Comprehensive Biochemical Genetics Requisition Form | Generated 11-18-2016 22:29:56 | Page 2/4 2165 North Decatur Road | Decatur, Georgia 30033 855-831-7447 | 404-778-8499 Fax: 404-778-8559 Scan for full test menu COMPREHENSIVE BIOCHEMICAL GENETICS TEST REQUISITION FORM DISEASE SPECIFIC REQUISITIONS: Please reference the respective disease-specific requisitions for comprehensive testing options available in all three laboratories. For sequential testing, indicate next to the test code the numerical order for testing to be processed. Example: (1) MCADD Mutation Panel, (2) MCADD Gene Sequencing indicates that (1) MCADD Mutation panel will be run first. If NEGATIVE, (2) MCADD Sequencing will be added. Note: Call to discuss prenatal molecular genetic testing with the laboratory genetic counselor PRIOR to sending a prenatal sample. 5 ml maternal blood in an EDTA (purple top) tube MUST accompany a prenatal specimen. PANEL TESTS AUTISM SPECTRUM DISORDERS SPECIMEN ❏ XC020 ❏ BB021 WB, PL, UR ** UR, PL ** Autism Spectrum Disorders - Complete Tier 1 Panel (Biochemical, Cytogenetic & Molecular) Autism Spectrum Disorders - Tier 1 Biochemical Panel GALACTOSEMIA ❏ GS SPECIMEN Galactosemia, Classic: Panel (GALT Activity & Gal-1-P), RBC If enzyme activity is determined to be consistent with classic or Duarte variant Galactosemia and you would like to automatically reflex to GALT full gene sequencing, please select test code SG, below. WB LYSOSOMAL STORAGE DISORDERS - ENZYME SPECIMEN ❏ LS WB LSD: Enzyme Panel (12 enzymes), WBC LYSOSOMAL STORAGE DISORDERS - SCREENING AND MONITORING SPECIMEN ❏ BLSDS ❏ BM UR SR, WB * Lysosomal Storage Disorders- Urine Screening Includes Test Codes GA & OS & BSAU Gaucher Disease: Biomarker Panel (ACE, CHITO, TRAP), Serum METABOLIC ANALYTES AND PROFILES SPECIMEN ❏ MW ❏ BNBSF UR, PL ** UR, PL ** Metabolic Disease: Panel, Plasma & Urine Includes Test Codes AA, AR, CN, & OA NBS Follow-up: Panel Methylmalonic Acidemia (MMA)/Propionic Acidemia (PA) Includes Test Codes AA, AR, CN, OA, HO, & MQ SINGLE ANALYTE AND GENE TESTS AUTISM SPECTRUM DISORDERS SPECIMEN ❏ XC020 WB, PL, UR ** UR, PL ** ❏ BB021 Autism Spectrum Disorders - Complete Tier 1 Panel (Biochemical, Cytogenetic & Molecular) Autism Spectrum Disorders - Tier 1 Biochemical Panel ❏ BKRBD ❏ LA ❏ LR CONGENITAL DISORDERS OF GLYCOSYLATION BIOCHEMICAL SPECIMEN ❏ BMPS6 ❏ BCDGP SR, PL * ❏ ❏ ❏ ❏ ❏ BCDGS ❏ BNGLY ❏ BOGLY ❏ ❏ OS CDG: Panel (Transferrin and N-glycan Analysis), Plasma CDG: Carbohydrate Deficient Transferrin, Plasma CDG: N-glycan Profile, Plasma CDG: O-Glycan Profile, Quantitative and Qualitative, Plasma 17q21 Microdeletion Syndrome High Resolution Oligosaccharide/Glycan Profile, Urine SR, PL * SR, PL * WB, PL * LQ DZ DW HC SPECIMEN ❏ AG WB 17q21 Microdeletion Syndrome GT SG DGALT GK GP GL WB WB, SV * WB, SV * WB WB UR LYSOSOMAL STORAGE DISORDERS - ENZYME SPECIMEN ❏ LS ❏ LM WB WB ❏ LO ❏ LN ❏ LB ❏ BGBCU ❏ LP ❏ LG LSD: Enzyme Panel (12 enzymes), WBC Alpha-Mannosidosis: Alpha-Mannosidase Activity, WBC Beta-Galactosidase deficiency (GM1, MPS IVB): Beta-Galactosidase Activity, WBC Beta-Mannosidosis: Beta-Mannosidase Activity, WBC Fabry Disease: Alpha-Galactosidase A Activity, WBC Fabry Disease: Gb3 Quantitative, Urine Fucosidosis: Alpha-Fucosidase Activity, WBC Gaucher Disease: Beta-Glucosidase Activity, WBC WB WB WB UR WB WB WB DBS WB WB UR ❏ GS ❏ ❏ ❏ ❏ ❏ ❏ WB ❏ BLSDS UR GALACTOSEMIA Galactosemia, Classic: Panel (GALT Activity & Gal-1-P), RBC If enzyme activity is determined to be consistent with classic or Duarte variant Galactosemia and you would like to automatically reflex to GALT full gene sequencing, please select test code SG, below. Galactosemia, Classic: GALT Activity, RBC Galactosemia - GALT Gene Sequencing Galactosemia - GALT Deletion/Duplication Galactokinase Deficiency: GALK Activity, RBC Galactosemia: Gal-1-P, RBC Galactosemia: Galactitol, Urine WB SPECIMEN ❏ GA ❏ BM ❏ DBS, WB * WB LYSOSOMAL STORAGE DISORDERS - SCREENING AND MONITORING SPECIMEN FISH ANALYSIS Krabbe Disease: GALC Activity, DBS Metachromatic Leukodystrophy: Arylsulfatase A Activity, WBC MPS I (Hurler): Alpha-L-Iduronidase Activity, WBC MPS VI (Maroteaux-Lamy): Arylsulfatase B Activity, WBC MPS VII (Sly): Beta-Glucuronidase Activity, WBC Pompe Disease: GAA Activity, DBS Pompe Disease: GAA Activity, WBC Tay-Sachs Disease, Hex A Activity ❏ CZ ❏ TT ❏ BSAU ❏ OS Lysosomal Storage Disorders- Urine Screening Includes Test Codes GA & OS & BSAU MPS: GAGs, Quantitative & Qualitative, Urine Gaucher Disease: Biomarker Panel (ACE, CHITO, TRAP), Serum Gaucher Disease: Biomarker Angiotensin Converting Enzyme (ACE), Serum Gaucher Disease: Biomarker Chitotriosidase (CHITO), Serum Gaucher Disease: Biomarker (TRAP), Serum Free Sialic Acid, Urine High Resolution Oligosaccharide/Glycan Profile, Urine UR SR, WB * SR, WB * SR, WB * SR, WB * UR * UR METABOLIC ANALYTES AND PROFILES SPECIMEN ❏ MW UR, PL ** ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ AR ED AA UA CN UC BCQLC CQ BCAHP BHOBS HO BMSUD BMMAD MQ Metabolic Disease: Panel, Plasma & Urine Includes Test Codes AA, AR, CN, & OA Acylcarnitine Profile, Plasma Amino Acid Profile, CSF Amino Acid Profile, Plasma Amino Acid Profile, Urine Carnitine Profile, Plasma Carnitine Profile, Urine CoQ10, WBC CoQ10, Plasma CAH: Steroid Profile, DBS Homocysteine, Total, DBS Homocysteine, Total, Plasma MSUD: Allo-isoleucine & BCAA, DBS MMA & MCA, Quantitative, DBS MMA, Quantitative, Plasma Comprehensive Biochemical Genetics Requisition Form | Generated 11-18-2016 22:29:57 | Page 3/4 PL SF PL UR PL UR WB PL DBS DBS PL DBS DBS PL 2165 North Decatur Road | Decatur, Georgia 30033 855-831-7447 | 404-778-8499 Fax: 404-778-8559 Scan for full test menu COMPREHENSIVE BIOCHEMICAL GENETICS TEST REQUISITION FORM ❏ BMMAU ❏ BNBSF ❏ OA ❏ ❏ ❏ ❏ ❏ OT FP ZF ZE BSLOS ❏ BSTRL MMA, Quantitative, Urine NBS Follow-up: Panel Methylmalonic Acidemia (MMA)/Propionic Acidemia (PA) Includes Test Codes AA, AR, CN, OA, HO, & MQ Organic Acid Profile, Quantitative & Qualitative, Urine Orotic Acid, Quantitative, Urine PKU: Phe & Tyr Monitoring, DBS Pyruvic Acid, Quantitative, Blood Pyruvic Acid, Quantitative, CSF Smith-Lemli-Opitz Screen- 7-dehydrocholesterol, Plasma Sterols, Plasma UR UR, PL ** UR UR DBS WB SF PL PL METABOLIC/NBS DISORDERS - MOLECULAR SPECIMEN ❏ SG ❏ DGALT WB, SV * WB, SV * Galactosemia - GALT Gene Sequencing Galactosemia - GALT Deletion/Duplication OTHER ENZYME ASSAYS ❏ BX STAT BIOCHEMICAL TESTING ❏ BARST ❏ BAAST ❏ BOAST SPECIMEN Biotinidase Deficiency: Biotinidase Activity, Serum SR SPECIMEN STAT: Acylcarnitine Profile, Plasma Must contact PL laboratory before receipt of sample. STAT: Amino Acid Profile, Plasma Must contact PL laboratory before receipt of sample. STAT: Organic Acid Profile, Quantitative & UR Qualitative, Urine Must contact laboratory before receipt of sample. For STAT testing please contact Biochemical Genetics Laboratory Director. * One specimen required, ** Both specimens required Preferred specimen types appear in bold text where applicable. Specimen Codes: AF - Amniotic Fluid, BM - Bone Marrow, CB - Cord Blood, CF - Cultured Fibroblasts, CTT - Colorectal Tumor Tissue, CV - Chorionic Villi, DBS - Dried Blood Spot, DNA - Isolated DNA, ETT - Endometrial Tumor Tissue, FCP - Fixed Cell Pellet, LP - Leukocyte Pellets, MB - Muscle Biopsy, PL - Plasma, PN Prenatal, SB - Skin Biopsy, SF - Spinal Fluid (CSF), SI - Special Instructions, SR - Serum, SV - Saliva, TB - Tissue Biopsy, TL - Transformed Lymphoblasts, UR Urine, WB - Whole Blood, WRB - Washed Red Blood Cells Comprehensive Biochemical Genetics Requisition Form | Generated 11-18-2016 22:29:57 | Page 4/4 Powered by TCPDF (www.tcpdf.org)
