General Request - mayocliniclabs.com

1 Page 1 of 3T239MC1360rev0921 General Request 2021 Mayo Foundation for Medical Education and ResearchVisit for the most up-to-date test and shipping specimens to: Mayo Clinic Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 855-516-8404 Billing Information An itemized invoice will be sent each month. Payment terms are net 30 the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US)Client Information (required)Client NameClient Account PhoneClient Order AddressCityStateZIP CodeInsurance InformationSubscriber Name (if different than patient)Relationship to Patient Spouse Dependent Other: _____Medicare HIC Number (if applicable)Medicaid Number (if applicable)Insurance Company Name (if applicable)Insurance Company Street AddressCityStateZIP CodePolicy NumberGroup NumberSubmitting Provider Information (required)Submitting/Referring Provider Name (Last, First)Fill in only if Call Back is (with area code)Fax (with area code)Provider s National (NPI)*Fax number given must be from a fax machine that complies with applicable HIPAA for Testing (required)ICD-10 Diagnosis CodePatient Information (required)Patient ID (Medical Record No.)

2 Patient Name (Last, First, Middle)Sex Male FemaleBirth Date (mm-dd-yyyy)Collection Date (mm-dd-yyyy)Time am pmStreet AddressCityStateZIP CodePhoneMCL Internal Use Only I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on file with this office or the individual s provider s office. SignatureNote: Test requests without a signature will not be performed. Note: It is the client s responsibility to maintain documentation of the York State Patients: Informed Consent for Genetic TestingPatient Information (required)Patient ID (Medical Record No.)Client Account No. Patient Name (Last, First, Middle)Client Order Date (mm-dd-yyyy)Page 2 of 3T239MC1360rev0921 PLASMA, SERUM, WHOLE BLOODP lasma ACTHA drenocorticotropic Hormone, Plasma PBKQNBK Virus DNA Detection and Quantification, Plasma CMVQNC ytomegalovirus (CMV) DNA Detection and Quantification by Real-Time PCR, Plasma HIVQNH I V-1 RNA Detection and Quantification, Plasma PMETM etanephrines, Fractionated, Free, Plasma PTHRPP arathyroid Hormone-Related Peptide, Plasma PLPP yridoxal 5-Phosphate (PLP), Plasma PRAR enin Activity, PlasmaSerum DHVD1,25-Dihydroxyvitamin D, Serum SFUNG1,3-Beta-D-Glucan (Fungitell), Serum OHPG17-Hydroxyprogesterone, Serum 25 HDN25-Hydroxyvitamin D2 and D3, Serum ALSA ldolase, Serum ALDSA ldosterone, Serum A1 APPA lpha-1-Antitrypsin Phenotype, Serum AFPA lpha-Fetoprotein (AFP) Tumor Marker, Serum MAFP1 Alpha-Fetoprotein (AFP)

3 , Single Marker Screen, Maternal, Serum ACEA ngiotensin Converting Enzyme, Serum ENAEA ntibody to Extractable Nuclear Antigen Evaluation, Serum AMH1 Antimullerian Hormone, Serum VASCA ntineutrophil Cytoplasmic Antibodies Vasculitis Panel, Serum ANA2 Antinuclear Antibodies (ANA), Serum NAIFAA ntinuclear Antibodies, HEp-2 Substrate, IgG, Serum ASPAGA spergillus (Galactomannan) Antigen, Serum B2 GMGBeta-2 Glycoprotein 1 Antibodies, IgG and IgM, Serum B2 MBeta-2-Microglobulin, Serum C2729 Breast Carcinoma-Associated Antigen, Serum CA19 Carbohydrate Antigen 19-9 (CA 19-9), Serum CDSPC eliac Disease Serology Cascade, Serum CERSC eruloplasmin, Serum CGAKC hromogranin A, Serum CUSC opper, Serum CPRC-Peptide, Serum CCPC yclic Citrullinated Peptide Antibodies, IgG, Serum ANCAC ytoplasmic Neutrophil Antibodies, Serum DHES1 Dehydroepiandrosterone Sulfate, Serum ADNADNA Double-Stranded Antibodies, IgG, Serum SPEPE lectrophoresis, Protein, Serum ENS2 Encephalopathy, Autoimmune Evaluation, Serum SEBVE pstein-Barr Virus (EBV) Antibody Profile, Serum EPOE rythropoietin, Serum GD65 SGlutamic Acid Decarboxylase (GAD65) Antibody Assay, Serum HAIGGH epatitis A IgG Antibody, Serum HBCH epatitis B Core Total Antibodies, Serum HBABH epatitis B Surface Antibody, Qualitative/Quantitative, Serum HBAGH epatitis B Surface Antigen, Serum HBVQNH epatitis B Virus (HBV) DNA Detection and Quantification by Real-Time PCR, Serum HCSRNH epatitis C Virus (HCV)

4 Antibody Screen with Reflex to HCV RNA, PCR, Asymptomatic, Serum HCVQNH epatitis C Virus (HCV) RNA Detection and Quantification by Real-Time Reverse Transcription-PCR (RT-PCR), Serum HSVGH erpes Simplex Virus (HSV) Type 1- and Type 2-Specific Antibodies, IgG, Serum IGEI mmunoglobulin E (IgE), Serum FLCSI mmunoglobulin Free Light Chains, Serum IGFMSI nsulin-Like Grow th Factor-1, Mass Spectrometry, Serum LAMOL amotrigine, Serum LEVEL evetiracetam, Serum LY WBLyme Disease Antibody, Immunoblot, Serum LYMELyme Disease Serology, Serum MMASM ethylmalonic Acid, Quantitative, Serum AMAM itochondrial Antibodies (M2), Serum PAVALP araneoplastic, Autoantibody Evaluation, Serum CLPMGP hospholipid (Cardiolipin) Antibodies, IgG and IgM, Serum PSAFTP rostate-Specific Antigen (PSA), Total and Free, Serum SMASS mooth Muscle Antibody Screen, Serum RT3T3 (Triiodothyronine), Reverse, Serum TGRPT estosterone, Total and Free, Serum TTSTT estosterone, Total, Mass Spectrometry, Serum TGABT hyroglobulin Antibody, Serum HTG2 Thyroglobulin, Tumor Marker, Serum TSIT hyroid-Stimulating Immunoglobulin, Serum TPOT hyroperoxidase Antibodies, Serum THYROT hyrotropin Receptor Antibody, Serum TTGAT issue Transglutaminase Antibody, IgA, Serum TRYPTT ryptase, Serum VZPGV aricella-Zoster Antibody, IgG, Serum VITAV itamin A, Serum VITEV itamin E, Serum ZNSZinc, SerumWhole Blood LY27BH L A - B 2 7, Blood PBDCLead, Capillary, with Demographics, Blood PBDVLead, Venous, with Demographics, Blood LDALDL ysosomal and Peroxisomal Disorders Newborn Screen, Blood Spot QF T4 QuantiFERON-TB Gold Plus, Blood TAKROT acrolimus, Blood TDPT hiamine (Vitamin B1)

5 , Whole BloodFECES CALPRC alprotectin, Feces OAPOva and Parasite, Concentrate and Permanent Smear, Microscopy, Feces ELASFP ancreatic Elastase, FecesURINE THCUC arboxy-Tetrahydrocannabinol (THC) Confirmation, Random, Urine CSMPUC ontrolled Substance Monitoring Panel, Random, Urine UHISTH istoplasma Antigen, Random, UrinePatient Information (required)Patient ID (Medical Record No.)Client Account No. Patient Name (Last, First, Middle)Client Order Date (mm-dd-yyyy)Page 3 of 3T239MC1360rev0921 MISCELLANEOUS CGRNAC hlamydia trachomatis and Neisseria gonorrhoeae, Nucleic Acid Amplification, Varies UBTH elicobacter pylori Breath Test HPVH uman Papillomavirus (HPV) DNA Detection with Genotyping, High-Risk Types by PCR, ThinPrep, Varies KIDSTK idney Stone Analysis CTBM ycobacteria and Nocardia Culture, Varies PATHCP athology Consultation COFLUS evere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA and Influenza Virus Type A and Type B RNA Detection, PCR, Varies COVIDS evere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA Detection, Varies COVOOS evere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA Detection, Varies SCOVHS evere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA, VariesADDITIONAL TESTS (INDICATE TEST CODE AND NAME)