DID YOU ICD Diagnosis Codes are Mandatory. PATIENT …

1 Aneuploidy Screening92777 QNatalTM Advanced for Fetal Chromosomal Abnormalities (as early as weeks gestation) DO NOT report (opt out) for microdeletions (subchromosomal copy variant) DO NOT report (opt out) for fetal sexCollection Date: _____/_____/_____ Two x 10mL Cell Free DNA Streck TubesEstimated Date of Delivery (EDD): _____/_____/_____ (mandatory)Number of Fetuses: One Two Three More than 3 Maternal Height:_____ in. Maternal Weight: _____ lbs)MEDICAL INDICATION FOR TESTING Select one or more ICD10 Codes if appropriate -or add additional code to describe clinical indicationHigh risk for fetal chromosomal aneuploidiesAdvanced Maternal Age: Primigravida 1st tri 2nd tri 3rd tri Multigravida 1st tri 2nd tri 3rd triAbnormal (MSS) serum biochemical screening: Other: Abnormal Ultrasound finding: (specify type[s]) Other: Personal or family history and add ICD10 code(s).

2 quest , quest diagnostics , the associated logo and all associated quest diagnostics marks are the trademarks of quest diagnostics . Copyright 2017 quest diagnostics Incorporated. All rights reserved. All other marks - ' and '- are the property of their respective owner. QD20840C. Revised 4 Diagnosis Codes are in the applicable fi elds HEREFOLD HERESPECIMEN KEY ON BACKSPECIMEN KEY ON BACKSPECIMEN KEY ON BACKP rovide signed ABN when necessaryProvide signed ABN when necessaryProvide signed ABN when necessaryProvide signed ABN when necessaryProvide signed ABN when necessarySMOOTHSEAL ICD Codes (enter all that apply)DATE COLLECTEDTIME : AM PMTOTAL VOL/HRS.

3 _____ ML _____ HR Fasting Non FastingNPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED) ADDIT L PHYS.: Dr. NPI/UPIN NON-PHYSICIAN # Fax Results to: ( ) Client # OR NAME: ADDRESS: CITY: STATE ZIP ACCOUNT #:NAME:ADDRESS:CITY, STATE, ZIPTELEPHONE #:Send Duplicate Report to:DID YOU KNOWBILL TO: My Account Insurance Provided Lab Card/Select PatientM M D D YEARDATEOFBIRTHREGISTRATION # (IF APPLICABLE)SEXPRINT PATIENT NAME (LAST, FIRST, MIDDLE)ROOM #--LAB REFERENCE #OFFICE / PATIENT ID # PATIENT SOCIAL SECURITY #( )APT.

4 # KEY # PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) PATIENT PHONE #PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENTM edicare LimitedCoverageTests@ = May not be covered for the reported = Has prescribed frequency rules for = A test or service performed with research/experimental = Has both Diagnosis and frequency-related coverage whennecessaryCITYRELATIONSHIP TO INSURED:SELFSPOUSEDEPENDENTINSURANCE ADDRESSSTATEZIPMEMBER / INSURED ID NO. #GROUP #PRIMARY INSURANCE CO. NAMEZIPSTATECITYPRIMARY INSURANCEABN required for tests with these symbolsICD Diagnosis Codes are in the applicable fields 866-GENE-INFO with any questions on test Appointment Website And Telephone Number Information Listed On The Sample Should Be Labeled With At Least Two PATIENT Identifiers At Time Of Prenatal ScreeningMany payers (including Medicare and Medicaid) have medical necessity requirements.

5 You should only order those tests which are medically necessary for the Diagnosis and treatment of the pregnancy with trisomy: Supervision of pregnancy with other poor reproductive or obstetric history, 1st tri Supervision of pregnancy with other poor reproductive or obstetric history, 2nd tri Supervision of pregnancy with other poor reproductive or obstetric history, 3rd tri Supervision of pregnancy with other poor reproductive or obstetric history, unspecified Supervision of other high risk pregnancies, 1st tri Supervision of other high risk pregnancies, 2nd tri Supervision of other high risk pregnancies, 3rd tri Supervision of other high risk pregnancies.

6 Unspecified trimesterRobertsonian translocation ICD10 code(s): Call 866-GENE-INFO with any questionsNeural Tube Defect Screening - Maternal Serum AFP@5059 Maternal Serum AFP (MSAFP) ( weeks gestation) 1 mL Red Top SSTDate of Birth: ____ /____ /_____ Collection Date: ____ /____ /____ Maternal Weight: _____ lbsEstimated Date of Delivery (EDD): ____ /____ /____ Determined by: Ultrasound Last Menstrual Period (LMP) Physical ExamMother s Ethnic Origin: African American Asian Caucasian Hispanic Other: _____Number of Fetuses: One Two More than 2 How many fetuses?

7 _____Yes No PATIENT is an insulin-dependent diabetic prior to pregnancy This is a repeat specimen for this pregnancy History of neural tube defect If yes, explain: Other Relevant Clinical Information: Informed Consent for Maternal Serum AFP1. Maternal Serum AFP (MSAFP) is offered to screen for open neural tube defects and may lead to the detection of 95% of fetuses with anencephaly and 65-80% of fetuses with open spina Neural tube defects (such as spina bifida and anencephaly) occur when the spine and brain do not develop Some open neural tube defects and those covered with skin may not be detected.

8 Most other birth defects and mental retardation are NOT detected by MSAFP Screen positive results mean further testing may be necessary to determine if the fetus has a neural tube defect. Such testing may include a repeat MSAFP test, ultrasound, or removal and testing of a small amount of amniotic fluid (amniocentesis).5. Screen positive results may occur for reasons such as: miscalculation of due date, twin pregnancy, vaginal bleeding, or the presence of other rare birth defects. Sometimes the results are screen positive for no apparent At the request of your physician, screen positive results will be given to a diagnostic center for certify that I have read the above consent and understand its content, including the BENEFITS and LIMITATIONS of Maternal Serum AFP Screening and request that it be performed.

9 I have discussed the test with my _____Patient Signature (required for New York residents only) Date_____ _____Physician Signature (required for New York residents only DateAneuploidy Screening92777 QNatalTM Advanced for Fetal Chromosomal Abnormalities (as early as weeks gestation) DO NOT report (opt out) for microdeletions (subchromosomal copy variant) DO NOT report (opt out) for fetal sexCollection Date: _____/_____/_____ Two x 10mL Cell Free DNA Streck TubesEstimated Date of Delivery (EDD): _____/_____/_____ (mandatory)Number of Fetuses: One Two Three More than 3 Maternal Height:_____ in.)

10 Maternal Weight: _____ lbs)MEDICAL INDICATION FOR TESTING Select one or more ICD10 Codes if appropriate -or add additional code to describe clinical indicationHigh risk for fetal chromosomal aneuploidiesAdvanced Maternal Age: Primigravida 1st tri 2nd tri 3rd tri Multigravida 1st tri 2nd tri 3rd triAbnormal (MSS) serum biochemical screening: Other: Abnormal Ultrasound finding: (specify type[s]) Other: Personal or family history and add ICD10 code(s): quest , quest diagnostics , the associated logo and all associated quest diagnostics marks are the trademarks of quest diagnostics .