Download Molecular Diagnostics Requisition Form

Molecular Diagnostics
ACCOUNT INFORMATION
Molecular Diagnostics Laboratory
2330 Inwood Road, Suite EB3.304
Dallas, Texas 75390
LAB PHONE: 214-648-0960
LAB FAX: 214-648-0967
CUSTOMER SERVICE: 214-645-7057
TOLL FREE: 877-887-8136
url:www.veripathlabs.com
CLIA #: 45D0861764
CAP #: 2664213
Account name:
Address:
City:
Zip code:
State:
Ph:
Fax:
REQUIRED ORDER INFORMATION
ICD-10 Code(s)
Medicare patients with non-covered diagnoses must sign
Signed ABN
Advanced Beneficiary Notice (ABN) available at: www.veripathlabs.com
included
or by calling customer service at 214-645-7057 or toll free 877-887-8136
ICD-10 Codes applicable to each and every test requested should come only from the ordering physician,
represent the reason for the test order at the time of order, and be supported by the patient’s medical record.
Physicians should order only tests that are medically necessary for the diagnosis or treatment of the patient.
Tests ordered should be single laboratory tests appropriate for the patient’s medical condition. Tests for
screening purposes may be ordered, but may not be reimbursed.
Patient Name: (Last, First, Middle)
Mother's Name: (if infant)
Date of Birth:
Sex:
Hospital Inpatient Y / N
Patient ID / MR#:
Collection Date:
Collection Time:
Phone:
AM
PM
:
NPI:
Ordering Physician (Full Name):
Pager:
Insured/Responsible Party Name: (if different from patient-Last, First, Middle)
Patient’s relationship:
Responsible Party Address: (street, city, State, zip)
Sex:
Phone:
Self
Spouse
Dependent
Other
FAX:
Clinical Indication
for Tests Ordered:
SPECIMEN INFORMATION
Whole Blood (EDTA preferred)
Plasma
(EDTA preferred)
Endocervical
ThinPrep® (Must be Endocervical)
Sorted Cells, source:
Fixed Paraffin Embedded Tissue
Source:
www.veripathlabs.com
PATIENT/3RD PARTY BILLING INFORMATION
Facility / Client
Patient / 3rd party – Billing information must be provided
BILL TO:
V E R I PAT H LAB O RATO RIES
Serum
Bone Marrow (EDTA preferred)
CSF
Swab in Viral Media
Urine
Employer's Name:
Employer's Phone:
Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Policy #:
Group #:
Medicare
Medicaid
Block # :
Other:
Date of Birth:
HMO
PPO
Member ID#:
Other
Referral Authorization/Precertification #:
Name:
TESTS REQUESTED
MOLECULAR ONCOLOGY
Date/Time:
INFECTIOUS DISEASE by PCR
BK viral load
Chlamydia and Gonorrhoeae, Urine or Thin Prep
 CMV viral load
 EBV viral load
 HCV viral load
 HPV high risk with genotyping, cervical
 HSV1 and HSV2
 VZV
 HHV-6
B-Cell Clonality PCR
T-Cell Clonality PCR
 BCL1/IGH: t(11;14) PCR
 BCL2/IGH: t(14;18) PCR
 BRAF mutations
 EGFR mutations
 ERBB2 mutations
 IDH1/IDH2 mutations
 JAK2 V617F mutation
 KIT in melanoma
 KRAS mutation analysis
 LOH for 1p/19q (brain tumors)
 MEK1 mutations
 NRAS mutations
 PIK3CA mutations




TRANSPLANT ANALYSIS
Pre-Transplant STR analysis
Donor Name____________________________________
Recipient Name_________________________________
 Post-Transplant STR Analysis

GENETIC MUTATIONS Ethnicity__________________________
Factor 2 (Prothrombin) 20210 G>A
Factor 5 Leiden
 MTHFR 677 C>T and 1298 A>C

CANCER MUTATION PANELS

Colon: KRAS, NRAS, BRAF
Lung: EGFR,KRAS, PIK3CA, ERBB2, BRAF, NRAS, MEK, AKT
 Melanoma: BRAF, C-KIT, NRAS
 50-gene Personalized Cancer Genomics panel by NGS


IDENTITY ANALYSIS BY MICROSATELLITE DNA

VERIPATH
USE
ONLY
MD - 051116
Transport Container:
Yellow
Trans Tube
Green
Total # of specimens:
Purple
Block
Syringe
Slides
Conical
Formalin
Red
Other:
Blue
Specimen contamination assessment (Lab Approval Required)
Transport Conditions:
Cup
Destination:
Initials:
Other
Frozen
Slushy
Coag
Cytogen
HemePath
Refrig
Room Temp
Flow
Hist
Mol Dx