Requisition Form – Prenatal

Requisition Form – Prenatal
Client Information
Prenatal Testing
Collection Date ________________________________ # Tubes ________________________
Specimen ID #(s) _______________________________________________________________
Sample Type
Referring Physician ________________________________ NPI ______________________
Genetic Counselor/Clinical Contact________________________________________________
Tel___________________________________ Fax _________________________________
Email _______________________________________________________________________
Patient Information
Last Name_____________________________ First Name____________________________
Street Address________________________________________________________________
q Chorionic villi q Cultured CVS
q Amniotic fluid
q Cultured amniocytes Pregnancy History
q Parental blood q DNA Source: _____________________
Gravida ___________
Para ___________
SAB ____________
TAB _____________
Is the pregnancy currently ongoing? q Yes q No, SAB/IUFD q No, TAB
How many fetuses? 1 2 3 Gestational age: ______ wks ______ days by q LMP q U/S
Fetal gender: q Female q Male q Unknown
Fetal karyotype: q 46,XX q46,XY qNot performed qPending qAbnormal NIPT results: qNot performed
q Normal
qAbnormal
*** If abnormal, please enclose a copy of the NIPT and/or karyotype report***
Prenatal Indications
q
q
q
q
Advanced maternal age (primagravida 659.53; multigravida 659.60)
Abnormal maternal serum screen (796.5)
Known or suspected chromosome abnormality in fetus (655.13)
A
bnormal findings on fetal ultrasound
***Please indicate abnormalities on the Phenotypic Checklist provided with the CombiMatrix Kits***
q Other ____________________________________ ICD-9 ___________________________
City, State Zip_________________________________________________________________
Prenatal Testing Options – CVS and Amniocentesis
DOB__________________________________ Gender_______________________________
q Amniotic fluid AFP with reflex to AChE
q CombiFISH™ (interphase FISH for 13, 18, 21, X, Y)
q CombiSNP™ microarray analysis
Tel___________________________________ Social Security #________________________
�CombiSNP™ Whole Genome Array
� CombiSNP™ Targeted Prenatal Array
Reflex to karyotype if microarray is normal? q Yes
q No
q Karyotyping on CVS or amniotic fluid
Reflex to microarray if karyotype is normal? q Yes
q No
Email_______________________________________________________________________
Medical Record Number_________________________________________________________
»» Information
Billing
Bill: _ q _My Account q Insurance q Medicare q Medicaid q Patient
Insurance Information q See attached
Insured Information
�CombiSNP™ Whole Genome Array
� CombiSNP™ Targeted Prenatal Array
Ancillary Prenatal Studies
q Fragile X
Name____________________________________________________
Relationship to Patient q Self
q Spouse
cc Fetal (available on cultured cells only; requires maternal blood sample)
cc Maternal (5 cc blood in EDTA)
q Child q Other:_______________________
Primary Insurance Company_______________________ Authorization #___________________
Group #
______________________ Insured # _____________________
Parental/ Family Studies – Peripheral Blood
Billing Address
________________________________________________________
q Maternal cell contamination (MCC) studies (select when ordering karyotype without microarray)
Billing City, State Zip
_______________________________________________________
Secondary Insurance Company_____________________ Authorization #___________________
Group #
_____________________ Insured #________________________
Billing Address
________________________________________________________
Billing City, State Zip
_______________________________________________________
q Parental analysis following abnormal POC or Prenatal microarray result
Mother’s Name: ________________________________
Mother’s DOB: _______________
Father’s Name: _________________________________
Father’s DOB: ________________
q Family member of a patient previously tested at CombiMatrix
Patient’s Name: ________________________________ Patient’s DOB: _______________
For Patient Bill cases, complete and submit “Self-Pay Testing Option” form. Testing will not be performed
unless a completed form is received.
Patient Authorization/Assignment
CombiMatrix Accession # or year study was performed: _____________________________________
I authorize CombiMatrix to obtain and release relevant medical and other information as needed to submit claims
to Medicaid, Medicare, or Medicare Supplemental for laboratory services CombiMatrix provides to me. I assign
insurance benefits to CombiMatrix and acknowledge that charges not covered by my insurance, including any
applicable co-payments or deductibles, are my responsibility, and I agree to pay them.
Please be sure to include as much information as possible regarding any fetal anomalies, as it
improves the quality of the interpretation of the microarray results.
Print Name of Patient or Guardian Signature of Patient or Guardian Special Instructions/Additional Testing Requests
Date (mm/dd/yyyy)
CombiMatrix | 310 Goddard, Suite 150, Irvine, CA 92618 | T: 800.710.0624 | F: 949.753.4725 | www.combimatrix.com
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