Sequencing Requisition Form

Ship To: O’Donoghue Research Bldg
1122 NE 13 Street, Suite 1400
Oklahoma City, OK 73104
Phone: 405‐271‐3589
Fax: 405‐271‐7117
A er hours phone: 405‐496‐9514
www.gene cs.ouhsc.edu
GENETICS LABORATORY
SEQUENCING REQUISITION FORM
Page 1 of 4
PLEASE COMPLETE ALL FORMS AND
SEND WITH PATIENT SAMPLE
REFERRING PHYSICIAN/FACILITY
Courier service in OKC metro area call
Rapid Transit 793‐1122 for specimen pickup
PATIENT INFORMATION
Physician Name ______________________________________________
Pa ent Name (last,first,m.)________________________________________
NPI__________________________________________________________
Parent Name (if pt is a minor)______________________________________
Phone(____)_________________ Fax(___)_______________
DOB_______________ SSN_____________________ MRN______________
Gene c Counselor_______________________ Phone(__)______________
Sex: □ Male □ Female □ Ambiguous □ Unknown □ Inpa ent □ Outpa‐
ent
Laboratory/Ins tu on___________________________________________
Address______________________________________________________
City_____________________ State________________ Zip_____________
Phone_(___)___________________ Fax (____)____________________
Ethnicity of pa ent (check all that apply)
□ African‐American □ Asian □Caucasian/NW European □ E. Indian
□ Hispanic □ Jewish‐Ashkenazi □ Jewish‐Sephardic □ Na ve American
□ Na ve Hawaiian/Other Pacific Islander □ Other__________________
Pa ent’s Address________________________________________________
SPECIMEN INFORMATION (Please refer to the third page for collec on requirements.)
□ Peripheral Blood
□ Amnio c Fluid/Cultured Amniocytes
Date Specimen Collected__________________________
□ Buccal Swab
□ Isolated DNA
Condi ons/Symptoms__________________________________________________________
TEST INFORMATION (Please Mark the Test(s) You are Reques ng)
□ Angelman syndrome
□ Bernard‐Soulier syndrome
□ Beta‐thalessemia
□ Bio nidase deficiency
□ CHARGE syndrome
□ Cockayne syndrome‐A
□ Costello syndrome
□ Cys c Fibrosis
□ Ehlers‐Danlos syndrome
□ Familial Hypercholesterolemia
□ Galactosemia
□ Isovaleric Acidemia
□ Hamartoma Tumor syndrome
□ Hereditary Papillary Renal Carcinoma
□ HLRCC
□ Kabuki syndrome
□ Li‐Fraumeni syndrome
□ Marfan syndrome
□ Marinesco‐Sjogren syndrome
□ MCAD
UBE3A GP1BB HBB BTD CHD7 ERCC8 HRAS CFTR CHST14 LDLR GALT IVD PTEN MET FH MLL2 TP53 FBN1 SIL1 ACADM □ Malignant Melanoma
□ Pancrea c Cancer
□ Re syndrome
□ SCAD
□ Sotos syndrome
□ TMD (Down's syndrome)
□ VLCAD
□ Von Hippel‐Lindau syndrome
□ Williams syndrome
□ Wilsons disease
□ Site Specific/Familial Muta on
CDKN2A PALB2 MECP2 ACADS NSD1 GATA1 ACADVL VHL ELN ATP7B (please include copy of lab report sta ng muta on sites)
ADDITIONAL REPORT
GENETICS LABORATORY USE ONLY
Physician/Facility______________________________________________
Laboratory Number__________________________________________
Phone_(___)_______________________ Fax_(___)__________________
Date/Time/Loca on of Pick‐Up or Delivery_______________________________
Address______________________________________________________
Ini als__________
_____________________________________________________________
Previous Lab Number_________________________________________
Check‐in___________
Ship To: O’Donoghue Research Bldg
1122 NE 13 Street, Suite 1400
Oklahoma City, OK 73104
Phone: 405‐271‐3589
Fax: 405‐271‐7117
A er hours phone: 405‐496‐9514
www.gene cs.ouhsc.edu
GENETICS LABORATORY
SEQUENCING REQUISITION FORM
Page 2 of 4
Pa ent Name Last_____________________________________________ First_________________________________________ MI______
TEST INFORMATION CONTINUED
Tests can be performed sequen ally or individually.
Genes are listed according to their prevalence in a disorder.
Adams‐Oliver syndrome
□ ARHGAP31 □ DOCK6 □ RBPJ □ EOGT Bar er syndrome
□ Type 1
□ Type 2
SLC12A1 KCNJ1 Cardiofaciocutaneous syndrome
□ BRAF □ MAP2K1 □ MAP2K2 □ KRAS □ SHOC2 Early Childhood Hearing Loss
□ Connexin 26 GJB2 □ Connexin 30 GJB6 Hereditary Breast & Ovarian Cancer
□ BRCA1 □ BRCA2 Hereditary Mul ple Osteochondromas
□ Type 1
□ Type 2
EXT1 EXT2 Hereditary & Idiopathic Chronic Pancrea
□ PRSS1 □ CFTR □ SPINK1 □ CTRC s panel
Hereditary Non‐Polyposis Colon Cancer/Lynch syndrome
□ MSH2 □ MLH1 □ MSH6 □ EPCAM Infan le Epilepsy
□ SCN1A □ SLC2A1 □ CDKL5 □ STXBP1 □ KCNQ2 □ KCNQ3 □ SCN2A Liddle syndrome
□ SCNN1B □ SCNN1G MODY
□ MODY2
GCK □ MODY3 HNF1A □ MODY1 HNF4A □ MODY5 HNF1B □ MODY4
PDX1 □ MODY6
NEUROD1 Mul ple Endocrine Neoplasia
□ Mul ple Endocrine Neoplasia 1
□ Mul ple Endocrine Neoplasia 2
Neurofibromatosis
□ Neurofibromatosis 1
□ Legius syndrome
□ Neurofibromatosis 2
Niemann‐Pick disease type C
□ NPC1 □ NPC2 Noonan syndrome
□ NS1 PTPN11 □ NS3 KRAS □ NS4 SOS1 □ NS5 RAF1 □ NS7 BRAF □ NS6 NRAS □ Seq
□ Seq
□ Seq
□ Seq
□ Seq
□ Seq
MEN1 RET NF1 SPRED1 NF2 ADDITIONAL REPORT
GENETICS LABORATORY USE ONLY
Physician/Facility______________________________________________
Laboratory Number__________________________________________
Phone_(___)_______________________ Fax_(___)__________________
Date/Time/Loca on of Pick‐Up or Delivery_______________________________
Address______________________________________________________
Ini als__________
_____________________________________________________________
Previous Lab Number_________________________________________
Check‐in___________
□ Del/Dup
□ Del/Dup
□ Del/Dup
□ Del/Dup
□ Del/Dup
□ Del/Dup
Ship To: O’Donoghue Research Bldg
1122 NE 13 Street, Suite 1400
Oklahoma City, OK 73104
Phone: 405‐271‐3589
Fax: 405‐271‐7117
A er hours phone: 405‐496‐9514
www.gene cs.ouhsc.edu
GENETICS LABORATORY
SEQUENCING REQUISITION FORM
Page 3 of 4
Pa ent Name Last_____________________________________________ First_________________________________________ MI______
TEST INFORMATION CONTINUED
Paraganglioma genes
□ SDHD □ SDHB □ SDHC □ SDHA □ SDHAF2 □ MAX Polyposis of the colon
□ MUTYH Associated Polyposis □ Familial Adenomatous Polyposis
□ Juvenile Polyposis
□ Juvenile Polyposis
Renal Tubular Acidosis
□ CA2 □ SLC4A1 □ ATP6V0A4 □ ATP6V1B1 □ SLC4A4 APC BMPR1A SMAD4 SPECIMEN REQUIREMENTS
Peripheral Blood
3‐5 cc in large EDTA tube (purple top), mix well. Keep specimen at room temperature or cooler, do not freeze.
Amnio c Fluid/Cultured Amniocytes
5‐10 cc in sterile centrifuge tubes. Keep specimen cool but do not freeze. DO NOT TRANSPORT SPECIMENS IN SYRINGES! Cultured amnio‐
cytes must be shipped in 2 T‐25 flasks.
Buccal swab (This specimen type can only be used for MCAD/SCAD; Peripheral blood is preferred ) Collect 3 specimens w/nylon brushes by
rubbing the brush firmly along the inside of the cheek for 10‐15 seconds. Place the cap on the brush, making sure it is ghtly sealed. Keep
fresh sample at room temperature.
Isolated DNA please contact lab to obtain concentra on and volumes that are required.
If shipping materials via Fedex/UPS packages can only be accepted Mon‐Fri 9:00 AM to 5:00 PM. Our facili es are not accessible by
delivery personnel on weekends or a er hours.
ADDITIONAL REPORT
GENETICS LABORATORY USE ONLY
Physician/Facility______________________________________________
Laboratory Number__________________________________________
Phone_(___)_______________________ Fax_(___)__________________
Date/Time/Loca on of Pick‐Up or Delivery_______________________________
Address______________________________________________________
Ini als__________
_____________________________________________________________
Previous Lab Number_________________________________________
Check‐in___________
GENETICS LABORATORY
BILLING INFORMATION FORM
Page 4 of 4
PATIENT NAME LAST_________________________________________ FIRST_____________________________________ MI________
YOU MUST CHOOSE ONE OF THE THREE BILLING OPTIONS LISTED BELOW.
PLEASE FORWARD ALL BILLING QUESTIONS TO DANIELLE OTIS AT [email protected] OR CALL 405‐271‐3589 OPT 4
AT THIS TIME WE DO NOT ACCEPT OUT OF STATE MEDICAID
PAYMENT OPTION 1‐INSTITUTION
INSTITUTION NAME _________________________________________________________________________________________________________
BILLING ADDRESS___________________________________________________________________________________________________________
CITY, STATE, ZIP ___________________________________________________________ CONTACT NAME___________________________________
PHONE NUMBER_____________________ FAX NUMBER_____________________ CONTACT EMAIL ADDRESS _______________________________
PAYMENT OPTION 2‐SELF PAY (PAYMENT MUST BE SENT WITH SAMPLE)
□ CREDIT CARD (CIRCLE ONE)
AMEX
DISCOVER VISA MASTERCARD
AMOUNT TO CHARGE___________________________
VALID CARD # ___________________________________________________________ EXP DATE_____________________________
CVC CODE ______________ CARDHOLDER PRINTED NAME___________________________________________________________
BILLING ADDRESS ___________________________________________ CITY, STATE, ZIP____________________________________
CARDHOLDER SIGNATURE ______________________________________________________________________________________
□ CHECK # ____________________________ AMOUNT ENCLOSED______________________________________
PAYMENT OPTION 3‐INSURANCE PROVIDE A LEGIBLE COPY OF THE FRONT & BACK OF INSURANCE CARD
Please Note: Currently Healthchoice, Humana Military (Tricare), and Medicare are NOT covering sequencing analysis.
PRIMARY INSURANCE POLICYHOLDER NAME ____________________________________ POLICYHOLDER DOB____________________
PRIMARY POLICYHOLDER SS# __________________________________ GENDER: M
RELATIONSHIP TO PATIENT_____________________________
F
EMPLOYER_________________________
POLICY # ________________________________________________
GROUP #_____________________________________________ INSURANCE CO. NAME _____________________________________
PHONE _____________________________________________
CLAIMS ADDRESS ________________________________________
CITY, STATE, ZIP_________________________________________
SECONDARY INSURANCE POLICYHOLDER NAME ________________________________ POLICYHOLDER DOB______________________
SECONDARY POLICYHOLDER SS# __________________________________ GENDER: M
RELATIONSHIP TO PATIENT______________________________
F
EMPLOYER________________________
POLICY # _________________________________________________
GROUP #_____________________________________________ INSURANCE CO. NAME ______________________________________
PHONE ______________________________________________
CLAIMS ADDRESS _________________________________________
I CONSENT TO HAVE THE TEST(S) LISTED ON THE PREVIOUS PAGE PERFORMED. I AUTHORIZE THE UNIVERSITY OF OKLAHOMA HSC GENETICS LABORATORY TO FURNISH
ANY MEDICAL INFORMATION REQUESTED ON MYSELF, OR MY COVERED DEPENDENTS. IN CONSIDERATION OF SERVICES RENDERED, I TRANSFER AND ASSIGN ANY BENEFITS OF INSURANCE TO UNIVERSITY OF OKLAHOMA HSC GENETICS LABORATORY. I UNDERSTAND I AM RESPONSIBLE FOR ANY CO-PAY, DEDUCTIBLES, OR NONAUTHORIZED SERVICES AND REMAINING BALANCES AFTER INSURANCE REIMBURSEMENT. I UNDERSTAND I AM FULLY RESPONSIBLE FOR PAYMENT OF MY ACCOUNT IF
THE UNIVERSITY OF OKLAHOMA HSC GENETICS LABORATORY IS NOT A PARTICIPANT WITH MY HEALTH PLAN, AND MY HEALTH PLAN DOES NOT FULLY REIMBURSE MY
MEDICAL SERVICES DUE TO LACK OF AUTHORIZATION OR MEDICAL NECESSITY.
PRINTED NAME ____________________________________________ SIGNATURE_________________________________________ DATE ________________