401 W. Morgan Road Ann Arbor MI 48108 844-4Armune (844-427-6863) www.armune.com Apifiny™ Test Requisition Form Page 1 of 2 Make a copy of completed form for your records PHYSICIAN AND DIAGNOSIS INFORMATION This Test C A N N O T be performed without the signature of the referring physician or other approved health care provider. Signature confirms your certification of medical necessity and that you have obtained patient’s permission for Armune BioScience to release test results to the patient’s third-party payer as necessary when submitting for reimbursement. Physician/Approved Provider Signature _____________________________________________________ Date ______________ Physician/Approved Provider Name (Print) _____________________________________________________________________ Laboratory/Hospital _______________________________________________________________________________________ Address ________________________________________________________________________________________________ City ______________________________________________________ State _________ ZIP __________ Country __________ Phone __________________________________ Ext ________ Secure FAX _________________________________________ E-Mail _______________________________________________ Report Final Results by:  Mail  Secure FAX  E-Mail Please state why test is needed (Diagnosis/Signs/Symptoms) ______________________________________________________ ICD-9:  222.2 Benign Neoplasm of Prostate  239.5 Neoplasm of Unspecified Nature of other Genetourinary Organs  600.90 Hyperplasia of Prostate, Unspecified 790.93 Elevated Prostate Specific Antigen (PSA)  Other _________ PATIENT INFORMATION Patient Name _____________________________________________________________ Date of Birth ____________________ Patient ID # ______________________________________________________________ Race __________________________ Address ________________________________________________________________________________________________ City ___________________________________ State _____ ZIP ________ Country __________ Phone ___________________ MEDICAL HISTORY Date(s)/Result(s) of Last PSA Test(s) ___________________ Date of Last DRE _________________________ Has Patient had a Prostate Biopsy?  No _____________________ Result of Last DRE  Yes ______________________  Normal  Abnormal If Yes, Pathology Result _______________________________________ SAMPLE INFORMATION Date and Time of Blood Draw ____________________ Sample Ship Date _____________ Number of Tubes ___________ Time Sample at 15-30°C ____________ PAYMENT INFORMATION Patient Payment Information (Check, Credit Card. Prompt payment discount will be processed when insurance coverage is determined.) Name on Card ____________________________________ Card No _________________________ Exp Date ___________ Security Code _______ Billing Address _____________________________________________________________________  Primary Private Insurance Carrier __________________________________ Attach front/back copy of insurance card Subscriber Name & Date of Birth _________________________________Subscriber’s relation to patient _______________  Secondary Private Insurance Carrier ________________________________ Attach front/back copy of insurance card Subscriber Name & Date of Birth _________________________________Subscriber’s relation to patient _______________  MEDICARE Attach front/back copy of insurance card  MEDICAID Attach front/back copy of insurance card  Hospital Inpatient (more than 24-hr stay)  Hospital Outpatient  Non-hospital patient © 2015 - Armune BioScience, Inc. FORM: CT-005 Rev. 02 04/21/15 PAGE 2 OF 2 Apifiny Blood Sample Collection and Handling Procedure s Please read carefully NOTE: A free prepaid sample mailer is available from Armune BioScience. To order, please contact [email protected], or call 844-4Armune (844-427-6863). 1. Follow standard blood-borne pathogen safety precautions. 2. Collect at least 5 mL of blood in red top tube(s). (Samples collected in blue top, green top, red/gray top, lavender top, or other tubes are not acceptable and will be rejected.) 3. Label tube(s) with patient’s name/ID, date and time of collection, and the Physician’s/Clinic’s name. NOTE: Please use reagent resistant ink or pencil for any hand-written labeling. 4. Store tube(s) at room temperature for at least 30 minutes after collection to allow the blood to clot, and then refrigerate. Ship promptly. Ship samples Monday through Thursday by FedEx overnight air delivery. Samples are accepted Tuesday through Friday only. 5. Send samples at 2° to 8ºC in a Styrofoam container with at least one frozen gel pack along with a packing list and the completed Apifiny Test Requisition Form for each sample. The packing list should include the total number of samples sent. Use a FedEx Clinical Pak and follow FedEx requirements and any other controlling regulations for packaging blood/serum for shipment. On the Domestic Airbill, Special Handling section, please check “No” for the question, “Does this shipment contain dangerous goods?” Samples for the Apifiny test are considered “non-infectious diagnostic specimens.” If you are using an Armune prepaid mailer, follow the packaging instructions that accompany the mailer. 6. Send samples by FedEx overnight air delivery to: Armune BioScience, Inc. 401 W. Morgan Road Ann Arbor, MI 48108 844-4Armune (844-427-6863) For additional sample collection and preparation information, or for more information about Armune’s laboratory, please refer to the Apifiny User Guide. The guide is available on-line at www.armune.com, through Armune Customer Support at [email protected] or by calling 844-4Armune (844-427-6863). © 2015 - Armune BioScience, Inc. FORM: CT-005 Rev. 01 04/03/15