Date of Birth Gender Ethnicity/Family History Male Female Unknown. (Institutional Billing only. We DO NOT bill patients directly.)
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1 PATIENT INFORMATION Last Name First M.I. CLINICAL LABORATORY Date of Birth Gender Ethnicity/Family History Male Female Unknown Molecular Diagnotics Patient or Sample ID# Institutional Account # (415) Fax (415) SPECIMEN INFORMATION SHIP TO: UCSF Clinical Laboratories Collection Date Type of Specimen Attn: Molecular Diagnostics Lab Serum Urine Product of Conception 185 Berry Street, Suite 100 Plasma CSF Tissue Origin: San Francisco, CA Collection Time Whole Blood CVS Other (specify): PLEASE SHIP MONDAY-THURSDAY ONLY Bone Marrow Amniotic Fluid CLIENT / BILLING INFORMATION (Institutional Billing only. We DO NOT bill patients directly.) Weeks Gestation: Institution Name Ordering Physician/Contact Person Telephone Fax # for Reports Department or Division Genetic Counselor Telephone Fax Address Billing Contact Telephone Fax City, State, Zip Billing Address (if different) City, State, Zip For Genetic Testing Only. As the ordering physician/provider, I certify that the patient has been appropriately informed of the test benefits and limitations. Adequate genetic counseling has been offered and written informed consent was obtained. Indication For Testing / Comments / Special Request: Physician/Provider Signature: Date: ICD9 Codes: INHERITED DISORDERS Tel: NEOPLASTIC DISORDERS Tel: MCC Maternal Cell Contamination (maternal and fetal samples) LAV 1P19Q 1p and 19q Deletion by FISH Tissue In addition to EDTA whole blood, most genetic tests listed here can also KDSQ ABL Kinase Domain Mutations LAV/BM be performed on amniotic fluid, CVS samples or cultured cells. For prenatal AML PANEL samples, we recommend also submitting a sample of EDTA whole blood FLT3 FLT3 Mutations, Qualitative PCR LAV/BM from the mother and ordering Maternal Cell Contamination (MCC). NPM1 NPM1 Mutation Detection LAV/BM ACGHC Array CGH, Constitutional LAV CEBPA CEBP Alpha Mutation Sequencing LAV/BM PCGH Array CGH, Family F/U LAV HACGH Hold Array CGH LAV BCRABL BCR/ABL Quantitative by PCR LAV/BM ALSC9 C9orf72 Repeat Expansion LAV BRAF BRAF V600E Mutation testing by RT-PCR Tissue POLT Cystic Fibrosis CBAVD Poly T Mutation LAV EGFR EGFR Amplification by FISH Tissue MCFM Cystic Fibrosis, PCR for Common Mutations LAV ERBB2 ERBB2 FISH (Breast Cancer, Her2/NEU) Tissue FRX Fragile X LAV EWSR1 EWSR1 Gene Rearrangement by FISH Tissue HHEM Hemochromatosis, Hereditary LAV ISO17Q Isochromosome 17q FISH Tissue INVN Hemophilia A Inversion LAV JAK2 Janus kinase 2 Mutation, Qualitative PCR LAV/BM HUNT Huntington's Disease Triplet Repeat LAV JMML JMML Associated Exon Panel (CBL, KRAS, NRAS, PTPN11) LAV/BM PWA Prader-Willi/Angelman Syndromes LAV FJMML JMML Associated Exon Panel, Family F/U LAV SMAPCR Spinal Muscular Atrophy LAV KRAS KRAS Sequencing Tissue THALASSEMIA & HEMOGLOBINOPATHY TESTING MSI Microsatellite Instability by PCR Tissue HbA % MCV fl Date of last transfusion: MGMT MGMT Promotor Methylation Assay Tissue HbF % RBC x10(9)/l MYC MYC FISH (C-MYC FISH) Tissue HbA2 % Fe g/dl Ethnicity: MYCN MYCN FISH (N-MYC FISH) Tissue Other Hb % Ferritin g/dl PMLR PML-RARA PCR, Qualitative LAV/BM HBEP Hemoglobinopathy w/evaluation by HPLC LAV PMLQNT PML-RARA PCR, Quantitative LAV/BM ATHL Alpha Thalassemia Mutations LAV PTEN PTEN Deletion by FISH Tissue HBCS Alpha Thalassemia Point Mutations LAV SS18 SS18 Gene Rearrangement by FISH Tissue BTHL Beta Thalassemia Mutations (incl. HbS, HbC, HbE) LAV UROV UroVysion (TM) FISH (Bladder Cancer) Urine BDEL Beta Globin Gene Deletions by PCR LAV BGSQ Beta-globin DNA Sequencing LAV PHARMACOGENOMICS TESTS Tel: C19 CYP2C19 Genotype LAV THROMBOSIS RISK IL28B IL28B Genotype LAV FVR Factor V (F5) Leiden Mutation LAV UGT1A1 UDP Glucosuronosyltransferase 1A1 LAV MTR Methylenetetrahydrofolate Reductase (MTHFR) mutation LAV WARF Warfarin Metabolism LAV PTTR Prothrombin (20210) mutation LAV OUTREACH SERVICES REQUISITION
2 CLINICAL LABORATORY - Outreach Testing Services Phone (415) Fax (415) Billing Questions: (415) UCSF Use Only Acct #: INSTITUTIONAL ACCOUNT FORM BILLING POLICY: UCSF Clinical Laboratories is unable to bill patients directly or accept any personal insurance plans from outpatients that are not seen at the UCSF Medical Center. An institution account must be established by referring institution prior to sending sample. To establish an account, please complete the required information below and fax to our office at An account # wil be assinged and an itemized invoice will be sent to the referring institution when the test has been completed. INSTITUTION INFORMATION INSTITUTION NAME ORDERING PHYSICIAN NAME DEPARTMENT/DIVISION ADDRESS PHONE (for specimen questions) CITY/STATE/ZIP FAX (For faxing Lab Results) BILLING CONTACT/ADDRESS NAME ADDRESS PHONE ADDRESS FAX CITY/STATE/ZIP GUARANTOR/AUTHORIZED SIGNATURE SIGNATURE PRINT NAME DATE For INTERNATIONAL Samples Only For INTERNATIONAL SAMPLES (outside US), prepayment is required by our Laboratory. Please contact our Laborartory to make arrangements. PLEASE FAX COMPLETED FORM TO (415) , Attn: Kelly Yang THANK YOU
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