Download Cardiology

Munroe-Meyer Institute for Genetics and Rehabilitation
UNMC Human Genetics Laboratory
Omaha, Nebraska | 402-559-5070
unmc.edu/geneticslab
CAP Accredited/CLIA# 28D0454363
CARDIOLOGY Test Request Form
A.
PAGE 1 / 2
PATIENT IDENTIFICATION
NAME:
DOB:
PHONE#:
B.
ADDRESS:
SPECIMEN INFORMATION
COLLECTION DATE:
MR/SSN#:
p FEMALE
p MALE
CITY/STATE/ZIP:
Access specimen requirements at www.unmc.edu/geneticslab
COLLECTION TIME:
SAMPLE TYPE:
p Blood
p Buccal
p DNA
NOTES:
C.
SINGLE TEST SELECTION
Gene lists available at www.unmc.edu/geneticslab
Cardiomyopathy Panel
p Comprehensive testing [ includes: seq, reflex to del/dup ]
p Sequencing ONLY
p Del/dup ONLY
Special Testing Consideration:
Please discuss with the patient before checking this box, as PSEN1 and
PSEN2 are also linked to Alzheimer’s disease. If this box is unchecked,
these genes will be blinded and will not be included in the patient’s results.
p Include PSEN1 and PSEN2 *available for patients > 19 years of age
D.
Single Gene Sequencing
p Proband (patient) - [specify gene]:
p Known familial variant - [specify gene]:
Relationship to affected individual:
Other Testing
p DNA Extraction and Cryopreservation only
p Other - [specify]:
PATIENT CONSENT
Informed consent MUST be signed.
If provider signs (instead of patient), s/he is acknowledging that s/he has reviewed this consent with the patient.
You have been offered genetic testing for inherited cardiac disease. This test may return with an abnormal result, meaning
it found a genetic change known to cause disease, a normal result, meaning it did not find a genetic change known to
cause disease in the genes tested, or a result of uncertain clinical significance, meaning it found a genetic change with a
currently unknown impact on cardiac health.
This test is designed to detect changes in genes that predispose a person to cardiac disease; however, it is capable of
uncovering genetic conditions in a family unrelated to cardiomyopathy, including early-onset Alzheimer’s disease. You may
choose not to be tested for PSEN1 and PSEN2, two genes thought to be responsible for ~1% of dilated cardiomyopathy,
but also known to cause an increased risk for early-onset Alzheimer’s disease. Testing may also reveal carrier status for
recessive or X-linked conditions, including Barth syndrome and Duchenne muscular dystrophy.
Test results may or may not allow for medical treatment, screening recommendations, or participation in research
studies. Test results may provide information for family members. Testing for family members may be important for
their own health management but may also require individuals to consider difficult decisions. Results may affect family
relationships. Results have the potential to reveal unexpected biological relationships, such as a different biological parent.
My questions have been answered, and I understand the benefits, risks, and limitations of this genetic testing.
Signature:
p
Date:
Check this box if you do not wish to have your DNA stored. Consent is implied if left unchecked.
4/2015
CONTINUE TO PAGE 2 ►
Munroe-Meyer Institute for Genetics and Rehabilitation
UNMC Human Genetics Laboratory
Omaha, Nebraska | 402-559-5070
unmc.edu/geneticslab
CAP Accredited/CLIA# 28D0454363
CARDIOLOGY Test Request Form
PAGE 2 / 2
PATIENT IDENTIFICATION

NAME:
E.
DOB:
MR/SSN#:
p FEMALE
p MALE
CLINICAL INFORMATION
ANCESTRY / FAMILY HISTORY AND CLINICAL INFORMATION: Attach family history, pedigree, or other clinical information, if available.
p African American
p Native American
p Ashkenazi Jewish
p Asian
p Western/Northern European
p Central/Eastern European
p Other:
p Latin American/Caribbean
p Middle Eastern
• INDICATIONS FOR TESTING:
F.
BILLING
Please contact our laboratory for insurance preauthorization assistance.
• ICD-9 CODE(S):
• CLIENT BILLING p
Facility:
Phone:
Address:
Fax:
City/State/Zip:
p Patient Insurance p Medicaid p Pending Medicaid
1) INCLUDE a clear, enlarged copy of both sides of the insurance card.
• INSURANCE / MEDICAID BILLING:
Policy Holder Name:
p Medicare
Policy Holder DOB:
2) VERIFY COVERAGE for genetic testing. Obtain pre-authorization when required (including Coventry, Tricare).
Authorization #:
Valid Date:
Expiration Date:
p Auth Pending
• PATIENT SELF-PAY p
G.
RESULT REPORTING
ORDERING PHYSICIAN:
ADDITIONAL REPORT TO:
Name: Name: Facility:
Facility:
Address:
Address:
City/State/Zip:
City/State/Zip:
Email:
Email:
H.
Fax:
Phone:
Fax:
Phone:
SHIPPING
Shipping supplies including collection kits, tubes, transport media, and prepaid airbills are available to our clients upon request.
LOCAL TRANSPORT: Call the laboratory (402-559-5070) to request specimen pickup.
OUT OF AREA TRANSPORT: Prior to shipping please fax this form to 402-559-7248 (include shipment tracking # in space provided below).
• Shipping Address: Human Genetics Laboratory - Zip 5440 / UNMC Shipping & Receiving Dock / 601 S Saddle Creek Road / Omaha NE 68106
Shipment Tracking #:
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EMAIL
END OF FORM ■