Comprehensive Test Requisition Form - Page 1 of 6

Transcription

1 Comprehesive Requisitio Form - Page 1 of 6 COMPLETE ENTIRE FORM AND SUBMIT PEDIGREE/CLINIC NOTES TO AVOID DELAYS patiet iformatio Name (Last, First, MI) Date of Birth (MM/DD/YY) Date of Death (If applicable) Phoe Number/ Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Address City State Zip Biological Sex F M Ethicity: Africa America Asia Caucasia Hispaic Jewish (Ashkeazi) Portuguese Other: specime iformatio*(for phlebotomy service, select all services you are requestig) Type(s) Blood (EDTA preferred) Saliva Buccal Swab^ DNA Cord Blood** Other**: Persoal history of allogeic boe marrow or peripheral stem cell trasplat Collectio Date Specime ID Medical Record # *Blood or saliva from patiets with active/recet hematological disease will udergo additioal review ad may ot be accepted i some cases. For these, cultured fibroblasts or fresh/fresh froze ormal tissue are preferred. See ambryge.com/specime-requiremets for details. **If submittig Cord Blood or a fetal specime, please see bottom of page 5 for Materal Cell Cotamiatio sample submissio test codes. ^Oly for Fragile X sydrome ad chromosomal microarray Phlebotomy Services Request: Phlebotomy draw Isurace preverificatio first Sed kit to patiet^ ^As the patiet's cliicia, I am uaware of ay potetial for complicatio or difficulty i drawig blood for the listed patiet(s). I uderstad that the phlebotomist has full authority to refuse to draw ay patiet if the safety of the phlebotomist ad/or patiet(s) are i questio. idicatio(s) for testig ICD-10 code(s): Will patiet maagemet be chaged depedig o the test results? Yes No preatal samples oly Sample type: Direct CVS Cultured CVS Cultured amio POC Cultured POC Gestatioal age at sample collectio 0rderig licesed provider/sedig facility (Each listed perso will receive a copy of the report) Facility Name (Facility ) Address City State /Coutry Zip Phoe Orderig Licesed Provider Name (Last, First)() NPI# Phoe Fax/ additioal results recipiets Geetic Couselor or Other Medical Provider Name (Last, First) () Phoe/Fax/ Geetic Couselor or Other Medical Provider Name (Last, First) () Phoe/Fax/ cofirmatio of iformed coset, pre-test geetic couselig, ad medical ecessity for geetic testig The udersiged perso (or represetative thereof) esures he/she is a licesed medical professioal authorized geetic testig ad cofirms that the patiet has give appropriate coset. I cofirm that testig is medically ecessary ad that test results may impact medical maagemet for the patiet. I agree to allow Ambry Geetics to facilitate the provisio of pre-test geetic couselig services by a third party service, Iformed DNA (uless otherwise oted), as required by the patiet s isurace provider (uless this box is checked ). Furthermore, all iformatio o this TRF is true to the best of my kowledge. My sigature applies to the attached letter of medical ecessity. Sigature Required for Processig Medical Professioal Sigature: Date: isurace billig (Iclude copy of both sides of isurace card) Patiet Relatio to Policy Holder? Self Spouse Child Isurace Compay Name ad DOB of Policy Holder (if ot self) Policy # HMO Auth # Out Of Pocket: We will start testig immediately, uless you check the box below. We will attempt to cotact you if your estimated out-ofpocket costs are > USD $100 Do ot start testig util I approve paymet terms regardig estimated out-of-pocket costs Patiet agrees to cotact regardig out-of-pocket amout by: Phoe (icludes texts) - cofirm mobile # Special Billig Notes: istitutioal billig Facility Name Sed ivoice to facility address above Address Cotact Name Phoe Number patiet paymet /Fax (Payable to Ambry Geetics) Credit Card (Call ) Patiet Ackowledgemet: I ackowledge that the iformatio provided by me is true ad correct. For direct isurace billig: I authorize my isurace beefits to be paid directly to Ambry Geetics Corporatio (Ambry), authorize Ambry to release medical iformatio cocerig my testig to my isurer, to be my desigated represetative for purposes of appealig ay deial of beefits as eeded ad to request additioal medical records for this purpose. I uderstad that I am fiacially resposible for ay amouts ot covered by my isurer ad resposible for sedig Ambry moey received from my health isurace compay. For patiet paymet by credit card: I hereby authorize Ambry Geetics Corporatio to bill my credit card as idicated above. I order to expedite cosideratio for eligibility for Ambry s Patiet Assistace Program, please provide the total aual gross household icome: $ ad the umber of family members i the household supported by the listed icome:. I authorize Ambry Geetics Corporatio to verify the above iformatio for the sole purpose of assessig fiacial eed, icludig the right to seek supportig documetatio. for y residets: I am a New York residet ad I give Ambry Geetics permissio to store my sample for loger tha 60 days. NOTE: If left blak, coset is iterpreted as NO. Sigature Required For Isurace/Self-Pay Patiets ad NY Sample Storage Coset: Date:

2 Patiet Name: DOB: Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Comprehesive Requisitio Form - Page 2 of 6 cliical history please attach pedigree /cliical cosultatio otes, if available Birth ad Neoatal History Not Applicable Developmetal History Not Applicable please submit the followig with the trf: 1. Cliic Notes 2. Pedigree 3. Isurace Card Gestatioal age at birth: Birth weight: Head circumferece at birth (if available): Cogeital aomalies, explai: Positive ewbor scree, explai: Seizure History Not Applicable Age at first uprovoked seizure (first seizure without fever or other acute metabolic or structural cause): Seizure types (choose all that apply): Ifatile/epileptic spasms Toic Atoic Are seizures: refractory well-cotrolled Has this patiet bee diagosed with a epilepsy sydrome? yes o ukow Pulmoology History Not Applicable Myocloic Typical absece Atypical absece Geeralized toic cloic Focal seizures If yes, please specify: Developmetal delay: yes o ukow Delay prior to seizure oset: yes o ukow N/A Type of delay (choose all that apply): motor laguage global Itellectual disability: yes o ukow Regressio or plateau: yes o ukow Does patiet meet DSM-V diagostic criteria for a autism spectrum disorder?: yes o ukow Cardiac History Not Applicable Sudde cardiac arrest Y N (if yes): # Episodes: Age first icidet: Sycope Y N If yes, # Episodes: Age first icidet: History of cardiomyopathy Y N Age at dx: Cardiomyopathy type: History of Arrhythmia Y N Age at dx: Arrhythmia type: Cogeital heart defect Positive ewbor scree CBAVD Mecoium ileus Ifectios: Sweat chloride: mmol/l Sweat chloride: < >60 Pacreatic isufficiecy IRT level: Respiratory distress, explai: Respiratory assistace devices: Ultrasoud fidigs: Cacer History Not Applicable previous test history (Please iclude copy of test results if performed at aother laboratory) Other History Not Applicable Hearig problems: Migraie: Visio problems: Psychiatric: Hematological: Suspected geetic coditio: Other cliical fidigs: Cacer/Tumor Age at Dx Pathology ad Other Ifo Brai Breast Type: ER (+) (-) uk PR (+) (-) uk HER2/eu (+) (-) uk 2d primary breast Type: ER (+) (-) uk PR (+) (-) uk HER2/eu (+) (-) uk Colorectal Locatio: Ovaria Fallopia tube Primary peritoeal Melaoma/ski Prostate Gleaso Score: Metastatic: Yes No Uterie Hematologic* Type: Allogeic boe marrow or peripheral stem cell trasplat* Other Cacer Type: GI polyps Adeomatous Other type: Polyp #: Polyp #: *Blood or saliva from patiets with active/recet hematological disease will udergo additioal review ad may ot be accepted i some cases. For these, cultured fibroblasts or fresh/fresh froze ormal tissue are preferred. See ambryge.com/specime-requiremets for details. Previously Detected Alteratio(s): Gee Name: ig Lab: Patiet previously tested at Ambry? Yes No Family previously tested at Ambry? Yes No Name: DOB: Relatio: family history (Completio of this sectio is required for orders icludig paretal samples) Mother - Name: DOB: uaffected affected, list symptoms/dx: Dx age: Father - Name: DOB: uaffected affected, list symptoms/dx: Dx age: Relatio to patiet Materal Pateral Disease Dx age

3 Patiet Name: DOB: Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Comprehesive Requisitio Form - Page 3 of 6 Please check the box ext to the test(s) beig ordered below. All tests iclude gee sequece ad deletio/duplicatio aalyses uless otherwise idicated. If this TRF is set to Ambry without or ahead of the sample, it will be treated as a preverificatio. If test ordered is differet tha the test preverified, we will hoor what is o the TRF order form with the sample. For multiple test orders, testig will be ru cocurretly (multiple tests iitiated at the same time) uless otherwise specified. To order reflexive testig (secod test starts pedig first test outcome), please clearly idicate the order of reflexive tests i the otes sectio or ext to the test check box. For reflex test orders, ay positive fidigs (pathogeic/likely pathogeic) i the first test will be reported out to the cliicia, ad the requested secod test will be caceled; all other fidigs will automatically reflex (icludig VUS). cacer Multi-Gee Orders Select the idicatio for testig: Hereditary polyposis 1 Lych sydrome/hnpcc 2 Hereditary breast ad ovaria cacer 3 ig is cliically idicated for other gee(s): Noe of the above To complete your multi-gee order, please select a test optio to the right. (See supplemetal iformatio o page 6 for details). 1 APC/MUTYH 2 MLH1, MSH2, MSH6, PMS2, EPCAM 3 BRCA1/2 * Required: completed CustomNext-Cacer supplemetal form. ambryge.com/forms Sigle Sydrome Orders BraiTumorNext gee brai tumor test BRCAplus gee breast cacer test BreastNext gee breast cacer test CacerNext gee cacer test CacerNext-Expaded gee cacer test ColoNext gee colorectal cacer test CustomNext-Cacer 9510 up to 81 gee custom test* GYNplus gee ovaria/uterie cacer test MelaomaNext gee melaoma test OvaNext gee ovaria/breast/uterie cacer test PacNext gee pacreatic cacer test Pacreatitis pael gee pacreatitis test PGLNext gee PGL/PCC test ProstateNext gee prostate cacer test RealNext gee real cacer test Name Descriptio Name Descriptio Breast ad/or Ovaria Cacer ATM 9014 Ataxia-telagiectasia BRCA1/ BRCA1/2 Ashkeazi Jewish 3-site mutatio pael BRCA1/2 Ashkeazi Jewish 3-site mutatio pael with reflex to BRCA1/2 aalysis if egative CHEK DICER PALB PTEN 2106 Hereditary breast ad ovaria cacer PTEN-related disorders (icludig Cowde sydrome) TP Li-Fraumei sydrome Edocrie Tumors MEN Multiple edocrie eoplasia type 1 RET gee sequece 2680 Multiple edocrie eoplasia type 2 Gastroitestial Cacer APC 3040 Familial adeomatous polyposis APC ad MUTYH cocurret BMPR1A ad SMAD4 cocurret 8726 Adeomatous polyposis 8604 Juveile polyposis sydrome CDH Hereditary diffuse gastric cacer EPCAM del/dup 8519 Lych sydrome Lych sydrome (cocurret) Lych sydrome (sequetial) 8517 MLH1, MSH2, MSH6, PMS2 + EPCAM del/dup 8515 Step 1: MLH1, MSH2, ad MSH6 + EPCAM del/dup; Step 2: PMS2 Gastroitestial Cacer (Cot.) MLH Lych sydrome MSH2 + EPCAM del/dup 8510 Icludes MSH2 iversio MSH2 iversio 2226 Lych sydrome MSH Lych sydrome MUTYH 4661 MUTYH-associated polyposis PMS Lych sydrome STK Peutz-Jeghers sydrome Geitouriary Cacer BAP FH 6301 Hereditary leiomyomatosis ad real cell cacer FLCN 5921 Birt-Hogg-Dubé sydrome VHL 2606 Vo-Hippel Lidau disease TSC1 ad TSC Tuberous sclerosis complex Ski Cacer/Melaoma CDKN2A ad CDK4 cocurret 4708 Familial atypical multiple mole melaoma (FAMMM) PTCH Gorli sydrome Other Hereditary Cacer ig NF Neurofibromatosis type 1 NF Neurofibromatosis type 2 RB Hereditary retioblastoma SMARCB Schwaomatosis Other Sigle Sydrome Orders Please visit ambryge.com/hereditary-cacer-sigle-gee-tests for details. (s): Gee/ Name(s):

4 Patiet Name: DOB: Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Comprehesive Requisitio Form - Page 4 of 6 cardiology Name Comprehesive Cardiovascular Paels CardioNext 8911 CustomNext-Cardio 9520 Arrhythmia Paels LogQTNext 8890 RhythmNext 8900 CPVTNext 8902 Cardiomyopathy Paels Descriptio 92 gees for hereditary cardiomyopathies ad arrhythmias Up to 167 gees related to hereditary cardiomyopathies, arrhythmias, TAAD, HHT, Nooa, ad lipidemias. Required: completed CustomNext-Cardio supplemetal form. ambryge.com/forms 17 gees for log QT, Brugada ad short QT sydromes 42 gees for log QT sydrome, Brugada ad short QT sydromes, CPVT ad ARVC 4 gees for catecholamiergic polymorphic vetricular tachycardia HCMNext gees for hypertrophic cardiomyopathy HCMNext Reflex 8883 MYBPC3, MYH7 reflex to HCMNext DCMNext gees for dilated cardiomyopathy CMNext gees for hereditary cardiomyopathy ARVCNext 8904 cliical geomics Karyotype 3660 Karyotype, rule out mosaic Hereditary leiomyomatosis real cell carcioma Maturity-oset diabetes of the youg Multiple edocrie eoplasia type I 3662 SNP Array 5490 Familial targeted microarray FH 11 gees for arrhythmogeic right vetricular cardiomyopathy 8310 HNF1A, HNF4A, HNF1B, GCK, PDX MEN1 Chromosome aalysis (requires greetop sodium-hepari tube) Chromosome aalysis (requires greetop sodium-hepari tube) Chromosomal microarray (>2.6 millio copy umber probes ad 750,000 SNP probes) Paid optio. Oly available followig SNP Array (5490) completed at Ambry. Icidetal fidigs urelated to the variat(s) detected i the probad, will NOT be reported. Name of probad tested at Ambry: ExomeNext-Probad 9993 Probad oly exome sequecig edocriology ExomeNext-Probad plus mtdna gastroeterology CFTR gee sequece ad deletio/duplicatio aalysis Hirschsprug disease (RET-related) hematology/ocology 9994 DBANext gees for Diamod-Blackfa aemia DCNext gees for dyskeratosis cogeita multiple cogeital aomalies Probad oly exome sequecig plus mtdna sequecig 1007 Report poly T/TG status 2680 RET gee sequece CHARGE sydrome 2380 CHD7 CdLSNext - Corelia de 7040 NIPBL, SMC1A, HDAC8, RAD21, SMC3 Lage sydrome Name Familial Hypercholesterolemia Multiple edocrie eoplasia type 2 ad familial medullary thyroid cacer (FMTC) Shwachma-Diamod sydrome 2680 RET gee sequece Neurofibromatosis type NF1 PGLNext gee PGL/PCC test vo-hippel Lidau disease 2606 VHL 1440 SBDS Descriptio FHNext gees (APOB, LDLR, LDLRAP1, PCSK9) this box if you would like to have the SLC01B1 c.521t>c polymorphism reported with FHNext, which has bee associated i medical literature with stati-iduced myopathies FCSNext (Familial Chylomicroemia Sydrome) 8920 APOA5, APOC2, GPIHBP1, LMF1, LPL Sitosterolemia 8930 ABCG5, ABCG8 Aeurysms ad Related Disorders TAADNext gees for thoracic aortic aeurysms/dissectios, Marfa sydrome, Ehlers-Dalos ad related disorders Marfa reflex to TAADNext 8783 FBN1 reflex to TAADNext Hereditary Hemorrhagic Telagiectasia (HHT) HHTNext 8672 ACVRL1, ENG, EPHB4, GDF2, RASA1, SMAD4 Nooa Sydrome NooaNext gees for RASopathies Other Trasthyreti amyloidosis 1560 TTR SNP Array* 5490 ExomeNext-Trio 9995 ExomeNext-Trio plus mtdna 9996 ExomeNext-Rapid 9999R Must be ordered through AP* ExomeNext-Select 9500 *AP is AmbryPort, our olie portal ambryge.com/ap Trio exome sequecig Opt-out of Cadidate (ovel) Geetic Etiologies Trio exome sequecig plus mtdna sequecig Opt-out of Cadidate (ovel) Geetic Etiologies Opt-out of Cadidate (ovel) Geetic Etiologies Up to 500 gee custom exome sequecig test If orderig ExomeNext/ExomeNext-Rapid, please complete: Secodary Fidigs Report: below to opt-out of the ACMG Recommeded List of secodary fidigs. If left uchecked, secodary fidigs will be reported. Secodary fidigs are ot available for ExomeNext-Select orders. Opt-out: I choose to declie the ACMG Recommeded List of secodary fidigs Juveile polyposis 8604 BMPR1A, SMAD4 sydrome Pacreatitis 8022 PRSS1, SPINK1, CFTR, CTRC Peutz-Jeghers sydrome 2766 STK11 Chromosomal microarray (>2.6 millio copy umber probes ad 750,000 SNP probes) Nooa sydrome 8402 PTPN11, SOS1, KRAS, RAF1

5 Patiet Name: DOB: Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Comprehesive Requisitio Form - Page 5 of 6 eurology Name Comprehesive Neuro ig CustomNext-Neuro 9540 Epilepsy EpiRapid 7033 EpiRapid reflex to EpilepsyNext 7034 EpiFirst-Fever 7011 EpiFirst-Focal 7017 EpiFirst-IS 7013 EpilepsyNext 7019 Hereditary Neuropathy Migraie pulmoology Familial trasthyreti amyloidosis Familial hemiplegic migraie 1560 TTR 7035 Cogeital Cetral Hypovetilatio Sydrome Cystic Fibrosis Cogeital cetral hypovetilatio sydrome 508 FIRST 1002 rheumatology Descriptio Up to 196 gee custom eurology test. if paretal samples are icluded 16 epilepsy gees with treatmet associatios 16 epilepsy gees with treatmet associatios, reflex to 100 gees for epilepsy 13 gees for febrile seizures if paretal samples are icluded 11 gee for o-lesioal focal epilepsy if paretal samples are icluded 17 gees for ifatile spasms if paretal samples are icluded 100 gees for epilepsy if paretal samples are icluded ATP1A2, CACNA1A, PRRT2, SCN1A if paretal samples are icluded Familial Mediterraea fever 5000 MEFV vascular CFTR gee sequece ad deletio/duplicatio aalysis EDS IV reflex to TAADNext Ehlers-Dalos type IV, vascular type 1580 PHOX2B gee sequece CFTR deltaf508 mutatio aalysis with reflex to CFTR gee sequece ad deletio/duplicatio Report poly T/TG status 1007 Report poly T/TG status 8791 COL3A1 reflex to TAADNext 8790 COL3A1 HHTNext 8672 ACVRL1, ENG, SMAD4, GDF2, RASA1 specific site aalysis (Please iclude a copy of relative's report) Name Neurodevelopmetal Disorders AutismNext 7024 Autism, macrocephaly 2106 PTEN Fragile X sydrome 4544 IDNext 7027 Neurodevelopmet- Expaded 7028 Descriptio Rett sydrome 2026 MECP2 Neurocutaeous/Neuro-Ocology Disorders Ataxia-telagiectasia 9014 ATM 48 gees for sydromic ad o-sydromic autism spectrum disorders if paretal samples are icluded FMR1 repeat expasio aalysis ad methylatio studies 140 gees for sydromic ad o-sydromic itellectual disability if paretal samples are icluded 196 gees for itellectual disability, autism spectrum disorders, ad epilepsy if paretal samples are icluded BraiTumorNext gees for brai tumors HHTNext 8672 ACVRL1, ENG, SMAD4, GDF2, RASA1 Legius sydrome 5724 SPRED1 Li-Fraumei sydrome 2866 TP53 Neurofibromatosis NF1 Neurofibromatosis NF2 Nevoid basal cell carcioma sydrome/ Gorli sydrome 5684 PTCH1 Tuberous sclerosis complex 5904 TSC1, TSC2 vo Hippel-Lidau disease 2606 VHL Marfa sydrome (MFS) MFS reflex to TAADNext 8781 FBN FBN1 reflex to TAADNext TAADNext gees for thoracic aortic aeurysms Gee(s): Mutatio(s): Relative Name: Relatioship to Relative: Accessio # (if tested at Ambry): Positive cotrol sample: will be provided already at Ambry ot available Primary Ciliary Dyskiesia PCDNext 8122 Pulmoary Fibrosis Telomere-related pulmoary fibrosis Respiratory Distress Sydrome Surfactat dysfuctio (respiratory distress sydrome) 21 gees for primary ciliary dyskiesia Report poly T/TG status 8140 TERT, TERC for preatal specimes or cord blood: materal cell cotamiatio (Both test codes required for fetal specimes) 8100 ABCA3, SFTPB, SFTPC gee sequece 1260 MCC for fetal specime or cord blood (ru cocurretly with test) 1262 MCC Referece for materal blood sample (No Charge)

6 Patiet Name: DOB: Aliso Viejo, CA USA Toll Free: Fax: ambryge.com Comprehesive TRF - Hereditary Cacer ig Supplemetal Iformatio - Page 6 of 6 Hereditary Cacer Multi-Gee s Name Gees Adeomatous polyposis 8726 APC, MUTYH BraiTumorNext (27 gees) 8847 AIP, ALK, APC, CDKN1B, CDKN2A, DICER1, MEN1, MLH1, MSH2, MSH6, NBN, NF1, NF2, PHOX2B, PMS2, POT1, PRKAR1A, PTCH1, PTEN, SMARCA4, SMARCB1, SMARCE1, SUFU, TP53, TSC1, TSC2, VHL BRCAplus (8 gees) 8836 ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, TP53 BreastNext (17 gees) 8820 ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, MRE11A, MUTYH, NBN, NF1, PALB2, PTEN, RAD50, RAD51C, RAD51D, TP53 CacerNext (34 gees) 8824 CacerNext-Expaded (67 gees) 8874 APC, ATM, BARD1, BRCA1, BRCA2, BRIP1, BMPR1A, CDH1, CDK4, CDKN2A, CHEK2, DICER1, EPCAM, GREM1, HOXB13, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, NF1, PALB2, PMS2, POLD1, POLE, PTEN, RAD50, RAD51C, RAD51D, SMAD4, SMARCA4, STK11, TP53 AIP, ALK, APC, ATM, BAP1, BARD1, BLM, BRCA1, BRCA2, BRIP1, BMPR1A, CDH1, CDK4, CDKN1B, CDKN2A,CHEK2, DICER1, EPCAM, FANCC, FH, FLCN, GALNT12, GREM1, HOXB13, MAX, MEN1, MET, MITF, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, NF1, NF2, PALB2, PHOX2B, POT1, PMS2, POLD1, POLE, PRKAR1A, PTCH1, PTEN, RAD50, RAD51C, RAD51D, RB1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, SMAD4, SMARCA4, SMARCB1, SMARCE1, STK11, SUFU, TMEM127, TP53, TSC1, TSC2, VHL, XRCC2 ColoNext (17 gees) 8822 APC, BMPR1A, CDH1, CHEK2, EPCAM, GREM1, MLH1, MSH2, MSH6, MUTYH, PMS2, POLD1, POLE, PTEN, SMAD4, STK11, TP53 CustomNext-Cacer (up to 81 gees) Required: complete CustomNext- Cacer supplemetal form. ambryge.com/forms 9510 AIP, ALK, APC, ATM, AXIN2, BAP1, BARD1, BLM, BRCA1, BRCA2, BRIP1, BMPR1A, CASR, CDC73, CDH1, CDK4, CDKN1B, CDKN2A, CFTR, CHEK2, CPA1, CTNNA1, CTRC, DICER1, EGFR, EPCAM, FANCC, FH, FLCN, GALNT12, GREM1, HOXB13, KIT, MAX, MEN1, MET, MITF, MLH1, MRE11A, MSH2, MSH3, MSH6, MUTYH, NBN, NF1, NF2, NTHL1, PALB2, PDGFRA, PHOX2B, POT1, PMS2, POLD1, POLE, PRKAR1A, PRSS1, PTCH1, PTEN, RAD50, RAD51C, RAD51D, RB1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, SMAD4, SMARCA4, SMARCB1, SMARCE1, SPINK1, STK11, SUFU, TMEM127, TP53, TSC1, TSC2, VHL, XRCC2 GYNplus (13 gees) 8835 BRCA1, BRCA2, BRIP1, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, PTEN, RAD51C, RAD51D, TP53 HBOC 8838 BRCA1, BRCA2 Lych sydrome/hnpcc 8517 MLH1, MSH2, MSH6, PMS2 + EPCAM del/dup MelaomaNext (8 gees) 8849 BAP1, BRCA2, CDK4, CDKN2A, MITF, PTEN, RB1, TP53 OvaNext (25 gees) 8830 ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, DICER1, EPCAM, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, NF1, PALB2, PMS2, PTEN, RAD50, RAD51C, RAD51D, SMARCA4, STK11, TP53 PacNext (13 gees) 8042 APC, ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, TP53 Pacreatitis pael (6 gees) 8022 CASR, CFTR, CPA1, PRSS1, SPINK1, CTRC PGLNext (12 gees) 5504 FH, MAX, MEN1, NF1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127, VHL ProstateNext (14 gees) 8845 ATM, BRCA1, BRCA2, CHEK2, EPCAM, HOXB13, MLH1, MSH2, MSH6, NBN, PALB2, PMS2, RAD51D, TP53 RealNext (19 gees) 5900 BAP1, EPCAM, FH, FLCN, MET, MITF, MLH1, MSH2, MSH6, PMS2, PTEN, SDHA, SDHB, SDHC, SDHD, TP53, TSC1, TSC2, VHL Updated Orderig Process (as of Jue 8, 2016) We have improved the orderig ad reportig process for our hereditary cacer paels. This helps cofirm that testig for oe or more of the followig gees is cliically idicated: APC, BRCA1, BRCA2, EPCAM, MLH1, MSH2, MSH6, MUTYH, ad PMS2. If you are orderig a multi-gee test, please first select a cliically idicated coditio ad complete your order by selectig a multi-gee order. Please idicate if your patiet meets cliical ad/or isurace testig criteria, or if the testig is otherwise cliically idicated for oe or more of the followig coditios: Adeomatous polyposis (APC/MUTYH) Hereditary breast ad ovaria cacer (BRCA1/2) Lych sydrome/hnpcc (MLH1, MSH2, MSH6, PMS2, EPCAM) If testig is ot cliically idicated for your patiet for ay of the listed optios, please either fill i the other gee(s) optio or select oe of the above. To complete your multi-gee order, please select oe of the appropriate test optios ad/or select other ad eter a appropriate test code(s)/test ame(s). For sigle gee orders, please select the appropriate test optio or eter the gee(s) ad/or test ame(s), as well as the relevat test code i the sigle gee orders sectio. For additioal details about our sigle gee testig optios, please visit ambryge.com/hereditary-cacer-sigle-gee-tests. Example: For a ColoNext multi-gee order, whe Lych testig is cliically idicated for the patiet EXAMPLE _v