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 © CombiMatrix. All rights reserved. ASR-F-092-10172014