Renal Diagnostics Test Request - MayoClinicLabs.com

1 Complete and print. Reset Form Renal Diagnostics Test Request Client Information (required) Patient Information (required). Client Name Patient ID (Medical Record No.). Client Account No. Patient Name (Last, First, Middle). Client Phone Client Order No. Sex Birth Date (mm-dd-yyyy). Male Female Street Address Collection Date (mm-dd-yyyy) Time am pm City State ZIP Code Ethnicity European/Caucasian African American Submitting Provider Information (required) Hispanic Asian Submitting/Referring Provider (Last, First) Other: _____. Fill in only if Call Back is required. Pathologist Name (required). Phone (with area code) Fax (with area code) Submitting/Referring Pathologist (Last, First). Provider's National (NPI) Phone (with area code) Fax (with area code). *Fax number given must be from a fax machine that complies with applicable *Fax number given must be from a fax machine that complies with applicable HIPAA regulation.

2 HIPAA regulation. Clinical Information MCL Internal Use Only Native biopsy Allograft biopsy: Transplant date (mm-dd-yyyy) : _____. Original disease: _____. Indications Hematuria Acute Renal failure Hypertension Systemic lupus Proteinuria Family history Diabetes Other, specify: _____. Ship specimens to: Billing Information Mayo Clinic Laboratories An itemized invoice will be sent each month. 3050 Superior Drive NW Payment terms are net 30 days. Rochester, MN 55901. Call the Business Office with billing related questions: Customer Service: 855-516-8404 800-447-6424 (US and Canada). 507-266-5490 (outside the US). Visit for the most up-to-date test and shipping information. T830. 2021 Mayo Foundation for Medical Education and Research Page 1 of 4 MC0767-11rev1121. Patient Information (required).

3 Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy). Renal PATHOLOGY LCBKP BK Virus, Molecular Detection, PCR, Plasma CRCL Creatinine Clearance, Serum and 24-Hour Urine Medical Renal Disease LCBK BK Virus, Molecular Detection, PCR, and Renal Transplant Monitoring Random, Urine CRTS1 Creatinine with Estimated GFR (CKD-EPI), BK Virus, Molecular Detection, Serum RPCWT Renal Pathology Consultation, Wet Tissue QBKU. Quantitative, PCR, Urine CSTCE Cystatin C with Estimated Glomerular RPCWT includes diagnostic interpretation of a Blood Urea Nitrogen (BUN), Serum Filtration Rate (eGFR), Serum medical kidney biopsy by integrating light microscopy, BUN. immunofluorescence, and electron microscopy EFPO Electrolyte and Osmolality Panel, Feces CAI calcium , Ionized, Serum findings together with clinical and laboratory data EOSU1 Eosinophils, Random, Urine for the patient.

4 CA calcium , Total, Serum HEXP Iohexol, Plasma Renal Pathology Tests CTU Creatinine, 24 Hour, Urine HEXU Iohexol, Timed Collection, Urine Available to Order Individually CRBF Creatinine, Body Fluid NSRC Iothalamate, Glomerular Filtration Rate, ALPRT Alport (Collagen IV Alpha 5 and Alpha 2) RCTUR Creatinine, Random, Urine Plasma and Urine Immunofluorescent Stain, Renal Biopsy Creatinine Clearance, Serum and CRCL. UOSMU Osmolality, Random, Urine AMPIP Amyloid Protein Identification, Paraffin, 24 Hour Urine LC-MS/MS UOSMS Osmolality, Serum CRTS1 Creatinine with Estimated GFR (CKD-EPI), DNJB9 DNAJB9 Immunostain, Technical Serum PHOS Phosphorus (Inorganic), Serum Component Only Cyclosporine, Blood Protein:Creatinine Ratio, Random, Urine CYSPR RPTU. MSFGN Fibrillary Glomerulonephritis CYCPK Cyclosporine, Peak, Blood 12PU1 Protein, Total, 12 Hour, Urine Confirmation, LC-MS/MS, Paraffin Tissue CSTCE Cystatin C with Estimated GFR, Serum PTU Protein, Total, 24 Hour, Urine HIGA Heavy-Light Chain IgA Kappa/IgA Lambda, Immunofluorescence CMVQN Cytomegalovirus (CMV) DNA Detection and TPBF Protein, Total, Body Fluid Quantification by Real-Time PCR, Plasma Protein, Total, Serum HIGG Heavy-Light Chain IgG Kappa/IgG Lambda, TP.

5 Immunofluorescence ELPSR Electrolyte Panel, Serum TPSF Protein, Total, Spinal Fluid HIGM Heavy-Light Chain IgM Kappa/IgM EBVQN Epstein-Barr Virus DNA Detection and RFAMA Renal Function Panel, Serum Lambda, Immunofluorescence Quantification, Plasma RB24 Retinol-Binding Protein, 24 Hour, Urine SUBIF Immunoglobulin G (IgG) Subtypes EVROL Everolimus, Blood Immunofluorescence, Tissue RBR Retinol-Binding Protein, Random, Urine MPA Mycophenolic Acid, Serum IGG4I IgG4 Immunostain, Technical Component SGUR Specific Gravity, Random, Urine PTH parathyroid Hormone (PTH) Immunostain, Only Technical Component Only URAU Urea, 24 Hour, Urine PLAIF Phospholipase A2 Receptor (PLA2R), Phosphorus (Inorganic), Serum URCON Urea, Random, Urine PHOS. Renal Biopsy KS Potassium, Serum RURC1 Uric Acid/Creatinine Ratio, Random, Urine THSIF Thrombospondin Type 1 Domain Containing 7A (THSD7A), RPTU Protein:Creatinine Ratio, Random, Urine URIC Uric Acid, Serum Immunofluorescence PTU Protein, Total, 24 Hour, Urine HEREDITARY Renal DISORDERS.

6 Note: As required, these tests are performed with RPCWT. RFAMA Renal Function Panel, Serum AGXTZ AGXT Gene, Full Gene Analysis, Varies KIDNEY FUNCTION / DIALYSIS / TRANSPLANT SIIRO Sirolimus, Whole Blood APOL1 APOL1 Genotype, Varies MONITORING TAKRO Tacrolimus, Blood APO1Z Apolipoprotein A-I (APOA1) Gene, Dialysis Montioring Kidney Function / Monitoring Full Gene Analysis, Varies AL Aluminum, Serum DHVD 1,25-Dihydroxyvitamin D, Serum APO2Z Apolipoprotein A-II (APOA2) Gene, UEBF Blood Urea Nitrogen, Body Fluid 25 HDN 25-Hydroxyvitamin D2 and D3, Serum Full Gene Analysis, Varies GDCRU Gadolinium/Creatinine Ratio, Random, ALB24 Albumin, 24 Hour, Urine ARPKZ Autosomal Recessive Polycystic Kidney Urine Disease (ARPKD), Full Gene Analysis, Varies ALBR Albumin, Random, Urine DOXA1 Oxalate Analysis in Hemodialysate AHUSP Complement-Mediated Atypical A124 Alpha-1-Microglobulin, 24 Hour, Urine Hemolytic-Uremic Syndrome (aHUS)/.

7 POXA1 Oxalate, Plasma Alpha-1-Microglobulin, Random, Urine Thrombotic Microangiopathy (TMA). RA1U. Transplant Monitoring Gene Panel, Varies HCO3 Bicarbonate, Serum 25 HDN 25-Hydroxyvitamin D2 and D3, Serum GSNZ Gelsolin (GSN) Gene, Full Gene Analysis, BUN Blood Urea Nitrogen (BUN), Serum Varies ALB24 Albumin, 24 Hour, Urine CLU Chloride, 24 Hour, Urine GRHPZ GRHPR Gene, Full Gene Analysis, Varies ALBR Albumin, Random, Urine RCHLU Chloride, Random, Urine LYZZ Lysozyme (LYZ) Gene, Full Gene Analysis, HCO3 Bicarbonate, Serum Varies CL Chloride, Serum PBKQN BK Virus DNA Detection and ATTRZ TTR Gene, Full Gene Analysis, Varies CTU Creatinine, 24 Hour, Urine Quantification, Plasma CRBF Creatinine, Body Fluid Note: Known Variant Testing Also Available . UBKQN BK Virus DNA Detection and call to order.

8 Quantification, Random, Urine RCTUR Creatinine, Random, Urine T830. Page 2 of 4 MC0767-11rev1121. Patient Information (required). Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy). ADDITIONAL Renal DISEASE TESTING PA2RE Phospholipase A2 Receptor Enzyme- CITR CITR Citrate Excretion, 24 Hour, Urine Linked Immunosorbent Assay, Serum Amyloidosis CITRA Citrate Excretion, Random, Urine PA2RI Phospholipase A2 Receptor Indirect APO1Z Apolipoprotein A-I (APOA1) Gene, HYOX Hyperoxaluria Panel, Urine Immunofluorescence Assay, Serum Full Gene Analysis, Varies Kidney Stone Analysis KIDST. PEISO Protein Electrophoresis and Isotype, Serum APO2Z Apolipoprotein A-II (APOA2) Gene, MAGU Magnesium, 24 Hour, Urine Full Gene Analysis, Varies PTU Protein, Total, 24 Hour, Urine MAGRU Magnesium/Creatinine Ratio, Random, GSNZ Gelsolin (GSN) Gene, Full Gene Analysis, THSD7 Thrombospondin Type-1 Domain- Urine Varies Containing 7A Antibodies, Serum OXU Oxalate, 24 Hour, Urine LYZZ Lysozyme (LYZ)

9 Gene, Full Gene Analysis, Hyperoxaluria Varies POXA1 Oxalate, Plasma AGXTZ AGXT Gene, Full Gene Analysis, Varies ATTRZ TTR Gene, Full Gene Analysis, Varies ROXUR Oxalate, Random, Urine GRHPZ GRHPR Gene, Full Gene Analysis, Varies Glomerular Disease - Nephritic POU Phosphorus, 24 Hour, Urine HYOX Hyperoxaluria Panel, Urine ALB24 Albumin, 24 Hour, Urine RPOU Phosphorus, Pediatric, Random, Urine OXU Oxalate, 24 Hour, Urine A124 Alpha-1-Microglobulin, 24 Hour, Urine SULFU Sulfate, 24 Hour, Urine DOXA1 Oxalate Analysis in Hemodialysate RA1U Alpha-1-Microglobulin, Random, Urine SAT24 Supersaturation Profile, 24 Hour, Urine POXA1 Oxalate, Plasma VASC Antineutrophil Cytoplasmic Antibodies SSATR Supersaturation Profile, Pediatric, ROXUR Oxalate, Random, Urine Vasculitis Panel, Serum Random, Urine Monoclonal Gammopathy Uric Acid, 24 Hour, Urine Note: Includes MPO and PR3 with reflex to ANCA URCU.

10 If positive. EPU Electrophoresis, Protein, 24 Hour, Urine Thrombotic Microangiopathy ANA2 Antinuclear Antibodies (ANA), Serum SPEP Electrophoresis, Protein, Serum ADM13 ADAMTS13 Activity and Inhibitor Profile, C3 Complement C3, Serum DMOGA Monoclonal Gammopathy Screen, Serum Plasma C4 Complement C4, Serum TMOGA Monoclonal Gammopathy Monitoring, AHUSD Atypical Hemolytic Uremic Syndrome Serum (aHUS) Complement Panel, Serum and CRY_S Cryoglobulin, Serum MPSU Monoclonal Protein Study, 24 Hour, Urine Plasma ANCA Cytoplasmic Neutrophil Antibodies, Serum Monoclonal Protein Study, Random, Urine AH50 Complement, Alternate Pathway (AH50), RMPSU. GBM Glomerular Basement Membrane Functional, Serum Antibodies, IgG, Serum PEISO Protein Electrophoresis and Isotype, Serum AHUSP Complement-Mediated Atypical MPO Myeloperoxidase Antibodies, IgG, Serum MALD Protein Isotype, Matrix-Assisted Laser Hemolytic-Uremic Syndrome (aHUS)/.