pharmacogenomics test request form

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PHARMACOGENOMICS TEST REQUEST FORM INSTRUCTIONS 1. 2.

Please complete this form in its entirety to ensure timely processing. Insert completed form with the sample when shipping.

PATIENT INFORMATION Last Name

First Name

Street Address

M/I

Date of Birth

City

Preferred Contact Phone No.

State

This Is A (select one)

□ HOME

Zip Gender

□ MOBILE

□ WORK

□ MALE

□ FEMALE

Race/Ethnic Identification

□ AFRICAN AMERICAN □ JEWISH - ASHKENAZI

□ ASIAN □ JEWISH - SEPHARDIC

□ CAUCASIAN □ NATIVE AMERICAN

□ HISPANIC □ OTHER: ______________

BILLING INFORMATION Please select a billing option below and provide a copy of the insurance card or credit card where appropriate.

Bill to:

□ DOCTOR

□ PATIENT (CC Needed)

□ INSURANCE (Ins. Card Needed)

COLLECTION INFORMATION Date Collected

Time Collected (AM/PM)

Collected by (Name and Signature)

PRACTICE/CLINIC INFORMATION Practice/Clinic Name

Practice/Clinic Phone No.

Practice/Clinic Address

CLINICIAN AUTHORIZATION Medicare regulations require the tests to be medically necessary for the diagnosis and treatment of the patient to qualify for reimbursement from the program. The physician must be treating the patient in connection with the diagnoses or complaints listed and this information must accurately reflect the medical reasons for requesting these tests. The medical necessity of each test ordered on this requisition must be documented in the patient’s medical record. Tests ordered for the purpose of screening, or which the physician believes to be appropriate even if the payor may not allow reimbursement, may not be billed to Medicare except for the purpose of receiving a denial. An Advance Beneficiary Notice (ABN) must be signed by the beneficiary or authorized person indicating willingness to assume financial responsibility for the testing.

Applicable Diagnosis Codes (ICD-10)

ABN Signed

□ YES

□ NO

Ordering Clinician Acknowledgement: I acknowledge that the tests ordered are medically necessary, and if ordered for the purpose of screening, or the likelihood of payment denial has been explained to the patient, prior to obtaining the laboratory specimen, who has signed the Advanced Beneficiary Notice and agreed to be financially responsible for payment of denied tests.

Clinician Name

Clinician NPI No.

Clinician Signature / Date

MEDICAL NECESSITY (check all applicable)

PATIENT MEDICAL INFORMATION

Please check the appropriate boxes below. If no options are applicable, please complete the Advanced Beneficiary Notice of Noncoverage (ABN) Form and append to this form.

Please attach a photocopy of patient Facesheet/Medsheet/EMR. Patient History/Reason for Ordering Tests/Comments

 Cytochrome P450 2D6 Testing: By checking this box you are indicating that the above patient’s gene testing is being used to guide medical treatment/dosing or considering medications for individual’s therapy with tricyclic antidepressants.  Cytochrome P450 2C19 Testing: By checking this box you are indicating that the above patient’s gene testing is being used to guide medical treatment/dosing or consider medications for individual’s therapy with Clopidogrel or a similar drug.

Current Medications Considered Medications

PANEL OPTIONS (do not check both Basic and Expanded Panels)

INDIVIDUAL TEST OPTIONS (optional)

Basic Panels

Expanded Panels (Requires ABN Form)

   

   

    

NeuroDx (incl. CYP 2D6, 2C9, 2C19) CardioDx (incl. CYP 2C19, 2D6, FII, FV, MTHFR) CompDx (incl. CYP 2C19, 2D6, FII, FV, MTHFR) ThromboDx (incl. FII, FV, MTHFR)

NeuroXP (incl. NeuroDx, 3A4, 3A5) CardioXP (incl. CardioDx, CYP 2C9, VKORC1) CompXP (incl. CompDx, CYP 2C9, VKORC1, 3A4, 3A5) NeuroPath

CYP 2D6 CYP 2C19 CYP 3A4 CYP 3A5 APOE

    

CYP 2C9 Factor II Prothrombin Factor V Leiden MTHFR VKORC1

NOTES

NextGen Laboratories, Inc. ▪ CLIA No. 05D0907431 3901 Westerly Place, Newport Beach, CA 92660 ▪ Tel: 800-219-6542 ▪ Fax: 949-272-3252

PersonalizeDx Laboratories, Inc. ▪ CLIA No. 05D2051580 2980 Scott St., Vista, CA 92801 ▪ Tel: 855-739-5669

PATIENT CONSENT INFORMED CONSENT OF GENETIC INFORMATION: I consent to having genetic analysis performed and the results of the analysis made available to my physician (where requested). This signed test request form authorizes PDXL to perform the test and disclose the results to my medical practitioner (where requested). No tests other than those requested above will be performed. I authorize PDXL to retain this specimen for future testing as requested.

Patient Name (please print)

Patient Signature

COMMON DIAGNOSIS ICD-10 CODES

ThromboDx

CardioDx

NeuroDx

For the convenience of the ordering physicians, the below ICD-10 codes are listed. Physicians are not required to use these codes but should report the diagnostic codes that best describes the reason for performing the test. MARK () ICD-10 DESCRIPTION F31.30 F31.31 F31.32 F31.4 F31.5 F31.60 F31.61 F31.62 F31.63 F31.64 F31.75 F31.76 F31.77 F31.78 F31.9 F32.9 F33.0 F33.1 F33.2 F33.3 F33.40 F33.41 F33.42 F33.9 G10 I20.0 I20.1 I20.8 I20.9 I21.09 I21.11 I21.19 I21.29 I21.3 I21.4 I24.0 I24.1 I24.8 I24.9 I25.110 I25.700 I25.710 I25.720 I25.730 I25.750 I25.760 I25.790 D68.32 D68.4 E66.01 I20.0 I24.1 I25.2 I26.90 I26.99 I63.40 I63.50 I66.9 I82.409 I82.4Y9 I82.4Z9 M62.3 M62.89 Z82.41 Z82.49 Z86.711 Z86.718 Z86.79

BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD OR MODERATE SEVERITY, UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE, WITHOUT PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE, WITH PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE MIXED, UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE MIXED, MILD BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE BIPOLAR DISORDER, CURRENT EPISODE MIXED, SEVERE, WITHOUT PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE MIXED, SEVERE, WITH PSYCHOTIC FEATURES BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE DEPRESSED BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE DEPRESSED BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE MIXED BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE MIXED BIPOLAR DISORDER, UNSPECIFIED MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITHOUT PSYCHOTIC FEATURES MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS MAJOR DEPRESSIVE DISORDER, RECURRENT, IN REMISSION, UNSPECIFIED MAJOR DEPRESSIVE DISORDER, RECURRENT, IN PARTIAL REMISSION MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED HUNTINGTON'S DISEASE UNSTABLE ANGINA ANGINA PECTORIS WITH DOCUMENTED SPASM OTHER FORMS OF ANGINA PECTORS ANGINA PECTORIS, UNSPECIFIED ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER CORONARY ARTERY OF ANTERIOR WALL ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING RIGHT CORONARY ARTERY ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER CORONARY ARTERY OF INFERIOR WALL ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER SITES ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION ACUTE CORONARY THROMBOSIS NOT RESULTING IN MYOCARDIAL INFARCTION DRESSLER'S SYNDROME OTHER FORMS OF ACUTE ISCHEMIC HEART DISEASE ACUTE ISCHEMIC HEART DISEASE, UNSPECIFIED ARTHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH UNSTABLE ANGINA PECTORIS ARTHEROSCLEROSIS OF CORONARY ARTERY BYPASS GRAFT(S), UNSPECIFIED, WITH UNSTABLE ANGINA PECTORIS ARTHEROSCLEROSIS OF AUTOLOGOUS VEIN CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS ATHEROSCLEROSIS OF AUTOLOGOUS ARTERY CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSTABLE ANGINA ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSTABLE ANGINA ATHEROSCLEROSIS OF OTHER CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS HEMORRHAGIC DISORDER DUE TO EXTRINSIC CIRCULATING ANTICOAGULANTS ACQUIRED COAGULATION FACTOR DEFICIENCY MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES UNSTABLE ANGINA DRESSLER'S SYNDROME OLD MYOCARDIAL INFARCTION SEPTIC PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE OTHER PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE CEREBRAL INFARCTION DUE TO EMBOLISM OF UNSPECIFIED CEREBRAL ARTERY CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF UNSPECIFIED CEREBRAL ARTERY OCCLUSION AND STENOSIS OF UNSPECIFIED CEREBRAL ARTERY ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED CEREBRAL ARTERY ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED PROXIMAL LOWER EXTREMITY ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED DISTAL LOWER EXTREMITY IMMOBILITY SYNDROME (PARAPLEGIC) OTHER SPECIFIC DISORDERS OF MUSCLE FAMILY HISTORY OF SUDDEN CARDIAC DEATH FAMILY HISTORY OF ISCHEMIC HEART DISEASE AND OTHER DISEASES OF THE CIRCULATORY SYSTEM PERSONAL HISTORY OF PULMONARY EMBOLISM PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM PERSONAL HISTORY OF OTHER DISEASES OF THE CIRCULATORY SYSTEM

NextGen Laboratories, Inc. ▪ CLIA No. 05D0907431 3901 Westerly Place, Newport Beach, CA 92660 ▪ Tel: 800-219-6542 ▪ Fax: 949-272-3252

PersonalizeDx Laboratories, Inc. ▪ CLIA No. 05D2051580 2980 Scott St., Vista, CA 92801 ▪ Tel: 855-739-5669