test requisition form - Emory University Department of Human Genetics

TEST REQUISITION FORM
2165 North Decatur Road | Decatur, Georgia 30033 | Phone: 404-778-8499 or 800-366-1502 | Fax: 404-778-8559 | http://geneticslab.emory.edu
PATIENT INFORMATION
Last Name ________________________ First _______________ MI____
DOB _______/_______/_______ Pt. ID/Med Rec# __________________
Address _____________________________________________________
____________________________________________________________
City __________________________ State ________ Zip _____________
Preferred Phone (______) _____________ - _______________________
Other # where pt. can be reached (______) __________ - _____________
Gender: Male Female Unknown Ambiguous
Parent name (if pt is a minor)/Spouse_____________________________
Ethnicity of pt. (check all that apply): African-American Asian
Caucasian/NW European E. Indian Hispanic Jewish-Ashkenazi
Jewish-Sephardic Mediterranean Native American
Native Hawaiian/Other Pacific Islander Other:________________________
PHYSICIAN ORDERING TEST (NPI Required)
Name________________________________________________________
NPI _________________________________________________________
Address _____________________________________________________
____________________________________________________________
City __________________________ State ________ Zip _____________
Phone (____) _______ - __________Fax (____) _______ - ___________
Email _______________________________________________________
Genetic Counselor ____________________________________________
Phone (____) _______ - __________Fax (____) _______ - ___________
Email_______________________________________________________
REFERRING HOSPITAL OR LABORATORY
Name________________________________________________________
NPI _________________________________________________________
Address _____________________________________________________
____________________________________________________________
City __________________________ State ________ Zip _____________
Phone (____) _______ - __________Fax (____) _______ - ___________
Email _______________________________________________________
DUPLICATE REPORT TO
Name________________________________________________________
Address _____________________________________________________
____________________________________________________________
City __________________________ State ________ Zip _____________
Phone (____) _______ - __________Fax (____) _______ - ___________
Email _______________________________________________________
INFORMATION FOR HEALTH CARE PROVIDERS AND PATIENTS
SPECIMEN INFORMATION
Date Collected ______ / _______ / _______ Time ______ : ______ AM PM
SAMPLE TYPE
Blood (B) Serum (S) Urine (U) Plasma (P) CSF DNA
Amniotic Fluid (AF) POC Chorionic Villi (CV) Saliva (SLV)
Fibroblast Cult (CF) Dried Blood Spot (BS) Other _________________
CLINICAL INFORMATION *REQUIRED*
Clinical findings/family history/test results (attach copies if appropriate)
Indication: Diagnostic Carrier
Is patient/spouse/family member pregnant?
No Yes Check if relevant: Egg donor Sperm donor
LMP_________________________ EDD_________________________
Genotypes Diet
Proband ___________________ Formula MCT Oil
Mother ____________________ Breast Milk Hyperal
Father ____________________ Special ___________________
Medications
Anticonvulsants Antidepressants Antibiotics HAF/TPN
Carnitine Oral Contraceptives Other __________________
Has Patient had any of the following?
Transfusion Bone Marrow Transplant
BILLING INFORMATION *Required*
ICD9 Codes:
Please complete billing information on page 2 of this form.
FOR LAB USE ONLY
Rec/d________/________/________ Unboxed By _____________________
Sender:________________________________________________________
TEMP SPECIMEN COLOR # TUBES COMP. INCOMP.
R C F PT. DATA [ ] [ ]
R C F TEST DATA [ ] [ ]
R C F BILLING DATA [ ] [ ]
# Pages PHYSICIAN DATA [ ] [ ]
Accessioned by: Labeled by: Pickup:
[ ] Facility Bill [ ] Insurance Bill [ ] Self Pay
Emory Genetics Laboratory retains patient samples indefinitely for validation, educational purposes and/or research. For molecular cytogenetic and some molecular genetic tests,
submitted clinical information and test results are also included in HIPAA-compliant, de-identified public databases as part of the National Institute of Health’s effort to improve
diagnostic testing and our understanding of the relationships between genetic changes and clinical symptoms (for information about the molecular cytogenetic database, visit the
consortium website at https://isca.genetics.emory.edu and for information about the molecular genetic database refer to the individual test descriptions). Confidentiality of each
sample is maintained. Patients may request to withdraw consent for the storage of their sample and/or use of the data by: 1) calling the laboratory at 1-800-366-1502 and asking
to speak with a laboratory genetic counselor or 2) visiting our website at http://www.geneticslab.emory.edu/opt-out.
[ ] Refusal for inclusion in these efforts may be indicated by checking this box. (If the box is not checked the data will be anonymized and used.)
NEW YORK STATE PATIENTS ONLY
Physician acknowledges the implications of genetic testing have been discussed with the patient and informed consent from the patient/guardian has been obtained.
Signature: Date: Rev. 6/17/2010

BILLING INFORMATION
2165 North Decatur Road | Decatur, Georgia 30033 | Phone: 404-778-8499 or 800-366-1502 | Fax: 404-778-8559 | http://geneticslab.emory.edu
Patient Name: Last________________________________ First _______________________________ MI _______
Submit this completed payment options form with the specimen. Billing policy information is available at http://www.geneticslab.emory.edu.
Note: Emory Genetics Lab (EGL) is a Medicare provider for laboratory services only. EGL does not accept non-Georgia Medicaid.
PAYMENT OPTIONS (please select an option)
1 - SELF PAY
Cashier Check Visa MasterCard Amount: $_______________
Credit Card #: ___________________________________________________________________________ Expiration Date: ________/_________
Cardholder Name: ________________________________________________________________________________________________________
Cardholder Billing Address____________________________________________________________________________________ Zip:___________
Cardholder Signature: (Required)_____________________________________________________________ Date:__________________________
2 - INSURANCE (Includes Wellcare, Amerigroup, Peachstate for GA Residents, GA Medicaid, and Medicare)
Front and back copy of insurance card and insurance authorization must be included. A completed Advance Beneficiary Notice of coverage (ABN) is
required for Medicare patients.
Policyholder Name: __________________________________________ SS#_________________________ DOB ____/____/_____
Relationship to the Patient: Self Spouse Dependent Other _____________________ Gender: Male Female
Name of Primary Insurance ______________________________ Policy No. _________________________ Group No. ________________________
Address ________________________________________________________________________________________________________________
City ___________________________________________ State ______________________ Zip _______________________
Name of Secondary Insurance ____________________________ Policy No. _________________________ Group No. _______________________
Address ________________________________________________________________________________________________________________
City ___________________________________________ State ______________________ Zip _______________________
Authorization Number: (from physician’s office) ______________________________________________________________________
AUTHORIZATION TO ASSIGN BENEFITS, AND ACCEPT FINANCIAL RESPONSIBILITY FOR MY ACCOUNT:
If I am entitled to benefits under the Medicare program, the Medicaid program, or any insurance policy or other health benefit plan, in consideration for services
provided to me by EGL, I assign, transfer and convey the benefits payable under such program, policy or plan for such services to EGL. I authorize payment of
benefits directly to EGL, with such benefits applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for
charges incurred by me and I agree to pay charges not paid under this assignment, including any coinsurance amounts and deductibles and any charges for services
deemed to be non-covered, not pre-certified or not preauthorized by my insurance plan.
Signature of Patient, Parent, or Guardian: (Required) ____________________________________________ Date: ______/______/______
3 - INSTITUTION - U.S. ONLY
Please call the billing office at 404-778-8580 or 800-366-1502 with questions or to establish an institutional account. You may also reach us via email at
domgbilling@emory.edu.
Contact Name: __________________________________________________ Client ID Number: __________________________________________
Institution: ____________________________________________________ Phone:__________________________ Fax: _______________________
Billing Address: ___________________________________________________________________________________________________________
City ___________________________________ State ___________ Zip ________________
Authorized Signature: (Required)_________________________________________________________________ Date: _______/_______/________
INFORMATION FOR HEALTH CARE PROVIDERS AND PATIENTS
CONTACT OF HEALTH INSURANCE CARRIER AND RELEASE OF CONFIDENTIAL MEDICAL INFORMATION:
I understand that EGL is permitted to disclose my health information for purposes of payment of bills (if I filled out section 2 above), my continued care or treatment,
and healthcare operations.
INTERNATIONAL SAMPLES
Payment in full must be made before samples will be processed. Payment by credit card can be indicated under option 1 above. Banker’s checks or money
orders must be made payable to Emory Genetics Laboratory. Please contact the EGL billing office for further arrangements or when you make an electronic fund
payment at (404) 778-8580 or domgbilling@emory.edu.
WIRE TRANSFER PAYMENT INFORMATION: For your convenience, Emory Genetics Laboratory can accept electronic fund payments, as follows:
Wachovia Bank, N.A., Atlanta, Georgia
Routing No.: 061-000-227 International SWIFT Code: PNBPUS533 Emory University Operating Account No.: 2000070083136
PLEASE INCLUDE: “For Emory Genetics Laboratory” and your Client and/or invoice number(s). Rev. 6/17/2010

TEST REQUISITION FORM
2165 North Decatur Road | Decatur, Georgia 30033 | Phone: 404-778-8499 or 800-366-1502 | Fax: 404-778-8559 | http://geneticslab.emory.edu
Patient Name: Last________________________________ First _______________________________ MI _______
For sequential testing, indicate in the 'Order' column, the numerical order for testing to be processed. Example: (1) MCADD Mutation Panel, (2) MCADD Gene Sequencing
indicates that (1) MCADD Mutation panel will be run first. If NEGATIVE, (2) MCADD Sequencing will be added.
Note: Call to discuss prenatal molecular genetic testing with the laboratory genetic counselor PRIOR to sending a prenatal sample. 5 ml maternal blood in an EDTA (purple top)
tube MUST accompany a prenatal specimen.
Order Whole Genome CGH Array Spec
Chromosomal Microarray, EmArray Cyto 60K B
Order Mental Retardation / Autism Spec
Autism Panel (Female) B
Autism Panel (Male) B
Fragile X FEMALE (CGG Rpts & Methylation) B
Fragile X MALE (CGG Rpts & Methylation) B
Specimen Codes: AF- Amniotic Fluid, B - Whole Blood, BM - Bone Marrow, BS - Dried Blood Spot, CF - Cultured Fibroblasts, CSF - Spinal Fluid, CV - Chorionic Villi
L - Leukocytes, M - Muscle, P- Plasma, POC - Product of Conception, RBC - Red Blood Cells, S - Serum, SLV - Saliva, Slides - Slides, T - Tumor Tissue, U - Urine Page 3/3