BTXNGS142 Met Solution Test Req v27 front - …

Please include the completed Test Requisition Form, pathology report,& patient insurance card(s) along with the specimenShip to Biotheranostics via FedEx Priority OvernightNameEmailPractice/Facility NameAddressCityStateZipPhoneFaxPATHOLOGI ST NameEmailAddressCityStateZipPhoneFaxName Social Security NumberAddressCityPhoneDOBS tateMedical Record #ZipSex M FBiopsy SiteSPECIMEN INFORMATION Reminder: Has pathologist reviewed tissue for adequacy?Block ID NumberDate Collected Fixative Type (Recommended 10% Neutral-Buffered Formalin)Clinical DiagnosisTESTING SERVICESP ractice/Facility NamePlease check if you are the ordering physicianPlease check if you are the ordering physicianNPINPI2. all fields belowNext Appt. DateYesNoSPECIMEN RETRIEVAL OPTIONI want Biotheranostics to request the specimen from Pathology (Please complete and fax this form to 800-266-9607)Test Requisition FormBiotheranostics, Inc. 9640 Towne Centre Dr., Suite 200 San Diego, CA 92121, USA Toll Free: (877) 886-6739 Fax: (800) 266-9607 ID Molecular diagnosis of tumor type & subtype ICD-10 Codes (Required) - List all codes that may apply (Visit for ICD-10 Code Reference Guide) *These biomarkers will be reported and billed separately by NeoGenomics.

• FFPE block preferred CTX-280 07/18 Page 2/2 • FFPE block preferred OR • 4-8 unstained, 3-4 micron sections on positively-charged slides, and 1 H&E slide

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