General Request Form - Mayo Medical Laboratories

1 Page 1 of 2T239 MC1360rev1118 General RequestClient Information (required)Client NameClient Account PhoneClient Order CodePatient Information (required)Patient ID ( Medical Record No.)Patient Name (Last, First, Middle)Gender Male FemaleBirth Date (Month DD, YYYY)Collection Date (Month DD, YYYY)Time s Street AddressPhoneCityStateZip CodeMML Internal Use OnlyShip specimens to: mayo Medical 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) 2018 mayo Foundation for Medical Education and ResearchInsurance Information (required)Subscriber s Name (if different than patient)Patient Relationship Spouse Dependent Other _____Medicare HIC Number (if applicable) Medicaid Number (if applicable)Insurance Company s Name (if applicable)Insurance Company s Street AddressCityStateZip CodePolicy NumberGroup Number 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.

2 Signature _____Note: It is the client s responsibility to maintain documentation of the order. Reason for Referral (required)ICD-10 Diagnosis CodeNote: It is the client s responsibility to maintain documentation of the order. New York State Patients: Informed Consent for Genetic TestingSubmitting Provider/Provider Name Information (required)Submitting/Referring Provider (Last, First)Fill in only if Call Back is ( ) _____ _____Fax * ( ) _____ _____Provider s National (NPI)*Fax number given must be from a fax machine that complies with applicable HIPAA for the most up-to-date test and shipping 2 of 2T239 MC1360rev1118 PLASMA, SERUM, WHOLE BLOODP lasma ACTHA drenocorticotropic Hormone (ACTH), Plasma CMVQNC ytomegalovirus (CMV)

3 DNA Detection and Quantification by Real-Time PCR, Plasma LUPPRL upus Anticoagulant Profile PMETM etanephrines, Fractionated, Free, Plasma PLPP yridoxal 5-Phosphate (PLP), Plasma PRAVASC Vascular Endothelial Growth Factor (VEGF), Plasma VASCV ascular Endothelial Growth Factor (VEGF), Plasma Serum DHVD1,25-Dihydroxyvitamin D, Serum OHPG17-Hydroxyprogesterone, Serum 25 HDN25-Hydroxyvitamin D2 and D3, Serum ALSA ldolase, Serum ALDSA ldosterone, Serum AFPA lpha-Fetoprotein (AFP) Tumor Marker, Serum DHESA ndrostenedione, Serum ACEA ngiotensin Converting Enzyme, Serum ENAEA ntibody to Extractable Nuclear Antigen Evaluation, Serum AMHA ntimullerian Hormone (AMH), Serum ANA2 Antinuclear Antibodies (ANA), Serum NAIFA Antinuclear Antibodies, HEp-2 Substrate, IgG, Serum B2 GMGBeta-2 Glycoprotein 1 Antibodies, IgG and IgM, Serum B2 MBeta-2-Microglobulin (Beta-2-M), Serum C2729 Breast Carcinoma-Associated Antigen (CA ), Serum CA19 Carbohydrate Antigen 19-9 (CA 19-9)

4 , Serum CDSPC eliac Disease Serology Cascade CERSC eruloplasmin, Serum CGAKC hromogranin A, Serum COMC omplement, Total, Serum CUSC opper, Serum CPRC-Peptide, Serum CCPC yclic Citrullinated Peptide Antibodies, IgG, Serum ANCAC ytoplasmic Neutrophil Antibodies, Serum ADNADNA Double-Stranded (dsDNA) Antibodies, IgG, Serum SPEPE lectrophoresis, Protein, Serum EMAE ndomysial Antibodies (IgA), Serum SEBVE pstein-Barr Virus (EBV) Antibody Profile, Serum EPOE rythropoietin (EPO), Serum GD65 SGlutamic Acid Decarboxylase (GAD65) Antibody Assay, Serum HBCH epatitis B Core Total Antibodies, Serum HBABH epatitis B Surface Antibody, Qualitative/Quantitative, Serum HBVQNH epatitis B Virus (HBV) DNA Detection and Quantification by Real-Time PCR, Serum HCVDXH epatitis C Antibody with Reflex to HCV RNA by PCR, 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 HSVH erpes Simplex Virus (HSV)

5 Type 1- and Type 2-Specific Antibodies, Serum HIVCOHIV-1 and HIV-2 Antigen and Antibody Evaluation, Serum IGGSIgG Subclasses, Serum IGEI mmunoglobulin E (IgE), Serum FLCPI mmunoglobulin Free Light Chains, Serum IGFMSI nsulin-Like Growth Factor-1, LC-MS, Serum INSI nsulin, Serum LAMOL amotrigine, Serum LEVEL evetiracetam, Serum LY WBLyme Disease Antibody, Immunoblot, Serum LYMELyme Disease Serology, Serum ROPGM easles (Rubeola) Antibodies, IgG, Serum MMASM ethylmalonic Acid (MMA), Quantitative, Serum AMAM itochondrial Antibodies (M2), Serum MPPGM umps Virus Antibody, IgG, Serum PAVALP araneoplastic, Autoantibody Evaluation, Serum CLPMGP hospholipid (Cardiolipin) Antibodies, IgG and IgM, Serum PSAFTP rostate-Specific Antigen (PSA), Total and Free, Serum SPISOP rotein Electrophoresis and Isotype, Serum SMAS mooth Muscle Antibodies, Serum PN23 Streptococcus pneumoniae IgG Antibodies, 23 Serotypes, Serum RT3T3 (Triiodothyronine), Reverse, Serum TGRPT estosterone, Total and Free, Serum TTFBT estosterone, Total, Bioavailable, and Free, Serum TTSTT estosterone, Total, Serum TGABT hyroglobulin Antibody, Serum HTG2 Thyroglobulin, Tumor Marker, Serum TSIT hyroid-Stimulating Immunoglobulin (TSI)

6 , Serum TPOT hyroperoxidase (TPO) Antibodies, Serum THYROT hyrotropin Receptor Antibody, Serum TTGAT issue Transglutaminase (tTG) Antibody, IgA, Serum TRYPTT ryptase, Serum VZPGV aricella-Zoster Antibody, IgG, Serum VITAV itamin A, Serum VITEV itamin E, Serum ZNSZinc, SerumWhole Blood HBELCH emoglobin Electrophoresis Cascade, Blood LY27 BHLA-B27, Blood PBDCLead, Capillary, with Demographics, Blood PBDVLead, Venous, with Demographics, Blood PLSDL ysosomal and Peroxisomal Storage Disorders Screen, Blood Spot QF T4 QuantiFERON-TB Gold Plus, Blood TAKROT acrolimus, Blood TDP Thiamine (Vitamin B1), Whole Blood FECES CALPRC alprotectin, Feces HPSAH elicobacter pylori Antigen, Feces OAPP arasitic ExaminationURINE AMPHUA mphetamines Confirmation, Urine BUPMB uprenorphine and Norbuprenorphine, Random, Urine THCUC arboxy-Tetrahydrocannabinol (THC) Confirmation, Urine OPATUO piates Confirmation, Urine PNCSUPain Clinic Survey, UrineMISCELLANEOUS CGRNAC hlamydia trachomatis and Neisseria gonorrhoeae by Nucleic Acid Amplification (GEN-PROBE) LHSVH erpes Simplex Virus (HSV), Molecular Detection, PCR HPVH uman Papillomavirus (HPV)

7 DNA Detection with Genotyping, High-Risk Types by PCR, ThinPrep CASAK idney Stone Analysis PATHCP athology ConsultationADDITIONAL TESTS (INDICATE TEST NUMBER AND NAME)Patient Information (required)Patient ID ( Medical Record No.)Client Account No. Patient Name (Last, First, Middle)Client Order Date (Month DD, YYYY)