Innovative Testing Requisition – Pathology
Client Information
Phone: (866) 776-5907
Fax: (239) 690-4237
Patient Information
Patient Name (Last, First):
Date of Birth: MM
/ DD
/ YY
Sex:
9 Male 9 Female
Medical Record #:
Social Security #:
Reason for Referral:
Requisition completed by:
(Please attach all relevant clinical history and pathology reports)
Ordering Physician (please print):
9 New Diagnosis 9 Relapse 9 In Remission
Ordering Physician Signature:
See Attached for Patient Address Information
Specimen Information
Coding Information
Specimen ID#:
Fixative/Preservative:
Collection Date:
/
/
Collection Time:
Diagnosis Code/ICD-9 Code (required):
9 AM 9 PM
9 Bone Marrow: Green Top(s)
Purple Top(s)
Core Biopsy
9 Peripheral Blood: Green Top(s)
Purple Top(s)
Other
9 Paraffin Block(s):
9 Fresh Tissue (Media Type required):
9 Slides: Stained
Unstained
Clot
Physician Notice: When ordering test(s), the physician is required to make an independent medical
necessity decision and provide the laboratory with ICD-9 code diagnosis information, from the
patient’s medical record, as billing support documentation.
Billing Information
Bill to:
Diagnosis: Please provide pathology report and any supporting documentation with specimen
9 Insurance/Medicare/Medicaid: A signed patient ABN is required when ordering
testing on this form for Medicare patients Medicare is 9 Primary 9 Secondary
9 Patient / Self-Pay
9 Client / Ordering Office
Prior Authorization Code / Number:
Comments
Tissue Type (check appropriate boxes and/or specify):
9 Colon
9 Other:
9 Lung
9 Gastric
9 Skin
A signed ABN is required when ordering testing on this form for Medicare patients.
NEOTYPE CANCER PROFILES
9 NeoTYPE™ Myeloid Disorders Profile (54 genes - See back for details)
9 NeoTYPE™ Solid Tumor Profile (48 genes - See back for details)
HEMATOLOGIC STAND-ALONE TESTS
9 ASXL1
9 ATRX
9 BCOR
9 BCORL1
9 BTK
9 CALR
9 CARD11
9 CBL
9 CBLB
9 CBLC
9 CDKN2A
9 CD79B
9 CSF3R
9 CUX1
9 CXCR4
9 DNMT3A
9 ETV6
9 EZH2
9 FBXW7
9 GATA1
9 GATA2
9 GNAS
9 HRAS
9 IKZF1
9 JAK3
9 KDM6A
SOLID TUMOR STAND-ALONE TESTS
9 MLL
9 MYD88
9 NOTCH1
9 NRAS
9 PHF6
9 PLC-Gamma-2
9 PTPN11
9 RAD21
9 SETBP1
9 SF3B1
9 SMC1A
9 SMC3
9 SRSF2
9 STAG2
9 STAT3
9 TET2
9 TP53
9 U2AF1
9 WT1
9 ZRSR2
9 AKT1
9 ALK
9 APC
9 ATM
9 CDH1
9 CDKN2A
9 CSF1R
9 CTNNB1
9 ERBB2
9 ERBB4
9 FBXW7
9 FGFR1
9 FGFR2
9 FGFR3
9 GNA11
9 GNAQ
9 GNAS
9 HNF1A
9 HRAS
9 JAK3
9 KDR
9 KRAS Exon 4
9 MET (c-MET)
9 MGMT Promoter
Methylation
9 MLH1Promoter
Methylation
9 NOTCH1
9 NRAS
9 PIK3CA
9 PTPN11
9 RB1
9 RET
9 SMAD4
9 SMARCB1
9 SMO
9 SRC
9 STK11
9 TP53
9 VHL
9 MLH1 Sequencing
OTHER TESTING / PANELS & PROFILES
9 MPN Extended Reflex Panel (JAK2, CALR, MPL)
9 NeoARRAY™ SNP / Cytogenetic Profile - For detection of copy number variants and loss of heterozygosity or uniparental disomy
9 BTK Inhibitor Resistance Panel (BTK, PLC-Gamma-2)
9 HOXB13 Genotyping
9 UGT1A1 Genotyping
9 Other:
9 Other:
9 Other:
Additional Stand-Alone tests are listed on the back of this requisition.
ABN VERIFICATION
9 SIGNED ABN IS ATTACHED: A signed ABN is required when ordering testing on this form for Medicare patients.
Innovative Pathology Req • Rev. 09.16.14
NEOTYPE HEMATOLOGY PROFILES
NEOARRAY SNP/CYTOGENETIC PROFILE
AML Favorable-Risk, AML Prognostic, JMML, MDS/CMML,
MPN, Myeloid Disorders
• Peripheral blood: 2x5 mL in EDTA tube.
• Bone marrow: 1-2 mL in EDTA tube, 2 mL preferred.
• Peripheral blood: 5 mL in EDTA tube.
• Bone marrow: 2 mL in EDTA tube.
• Fresh tumor tissue: 0.5 – 1 cm3 in RPMI.
CLL Prognostic
• Peripheral blood: 2x5 mL in EDTA tube.
• Bone marrow: 1-2 mL in EDTA tube, 2 mL preferred.
• Fresh tissue: 0.5 - 1 cm3 in RPMI.
Lymphoma
• Peripheral blood: 2x5 mL in EDTA tube.
• Bone marrow: 1-2 mL in EDTA tube, 2 mL preferred.
• Fresh tissue: 0.5 - 1 cm3 in RPMI.
• FFPE tissue: Paraffin block (preferred) or one H&E slide
plus 5-10 unstained slides cut at 5 or more microns.
Please use positively-charged slides and 10% buffered
formalin fixative. Do not use zinc fixatives.
NEOTYPE™ CANCER PROFILES
• NeoTYPE™ Myeloid Disorders Profile (54 Genes): ABL1 · ASXL1 · ATRX · BCOR · BCORL1 · BRAF · CALR · CBL · CBLB ·
CBLC · CDKN2A · CEBPA · CSF3R · CUX1 · DNMT3A · ETV6 · EZH2 · FBXW7 · FLT3 · GATA1 · GATA2 · GNAS · HRAS · IDH1 ·
IDH2 · IKZF1 · JAK2 V617F · JAK2 Exon 12+14 · JAK3 · KDM6A · KIT · KRAS · MLL · MPL · MYD88 · NOTCH1 · NPM1 · NRAS ·
PDGFRA · PHF6 · PTEN · PTPN11 · RAD21 · RUNX1 · SETBP1 · SF3B1 · SMC1A · SMC3 · SRSF2 · STAG2 · TET2 · TP53 · U2AF1 ·
WT1 · ZRSR2 · interpretation
• NeoTYPE™ Solid Tumor Profile (48 Genes): ABL1 · AKT1 · ALK · APC · ATM · BRAF · CDH1 · CDKN2A · CSF1R · CTNNB1 ·
EGFR · ERBB2 · ERBB4 · FBXW7 · FGFR1 · FGFR2 · FGFR3 · FLT3 · GNA11 · GNAQ · GNAS · HNF1A · HRAS · IDH1 · JAK2 ·
JAK3 · KDR · KIT · KRAS · MET · MLH1 · MPL · NOTCH1 · NPM1 · NRAS · PDGFRA · PIK3CA · PTEN · PTPN11 · RB1 · RET ·
SMAD4 · SMARCB1 · SMO · SRC · STK11 · TP53 · VHL · interpretation
MPN EXTENDED REFLEX PANEL
• JAK2 V617F is run first. JAK2 Exon 12-14 will be run when V617F is negative. CALR will be run when JAK2 Exon 12-14 is
negative. MPL will be run when CALR is negative.
ADDITIONAL STAND-ALONE TESTS
• No ABN or Insurance Patient Notice of Financial Responsibility is required for these tests: ABL1 · BCL1 · BCL2 · BRAF ·
CEBPA · EGFR · FLT3 · IDH1 · IDH2 · IgVH · JAK2 V617F · JAK2 Exon 12+14 · KIT · KRAS · Microsatellite Instability · MPL ·
NPM1 · PDGFRA · PTEN · RUNX1
• Please find non-billing restricted testing options on our regular family of requisitions.

Presentation (PDF) - WIN 2015 Symposium

Implications for allotransplantation in the Lymphoma Setting

• Cell line panel profiling reveals that MEK inhibitors can be