Fillable Add-On Test Authorization - Hematopathology Patients insurance information (CellNetix Pathology & Laboratories)

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Add-On Test Authorization - Hematopathology Patients insurance information (CellNetix Pathology & Laboratories)

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_______________________________________________________________________________________________
REQUIRED - Physician or authorized designee signature
_______________________________________________________________________________________________
PRINT NAME
For CellNetix Use Only-
010621
Date Received: SSS Initials:
Pathologist Initials:
NGS_Myeloid Hotspot Panel (37 genes for AML, MPN, MDS, CMML)
Bone Marrow Aspirate
Bone Marrow Biopsy
Paraffin Block
Peritoneal Fluid
Pleural Fluid
Peripheral Blood
Other:________________________________________________________________________________________________
Specimen Information
CSF (Transport ASAP at 2-8 C)
FNA (Transport ASAP at room temperature)
Fresh Tissue Biopsy
Specimen Type: ___________________
Media Type: ______________________
Other _____________________________
O
Disease State
Presentation
Known Diagnosis __________________
MRD/Post Therapy (Days post Rx _______)
Recurrence
Tissue Specimens for Histology
Time in Formalin ___________________
A _______________________________
B _______________________________
C _______________________________
D _______________________________
Clinical Information
_______________________________________
_______________________________________
_______________________________________
_______________________________________
BCR-ABL1 Screen (p210+p190), Quant RT-PCR
BCR-ABL1 p210 Quant RT-PCR
BCR-ABL1 p190 Quant RT-PCR
JAK2_V617F by PCR
CALR Ex9 indels by PCR
MPL_W515K/L by PCR
JAK2_V617F and CALR and MPL
JAK2_V617F ref to CALR / MPL
JAK2_V617F ref to CALR / MPL / JAK2_Ex12-16
JAK2_V617F ref to Ex12-16
JAK2_Ex12-16 sequencing
Next Generation Sequencing
Flow Cytometry
Mature B, T, & NK Cell Neoplasms
Precursor Lymphoid Neoplasms (B-ALL, T-ALL)
Plasma Cell Panel
Mastocytosis
FISH
Chronic Lymphocytic Leukemia (CLL) Panel
FLT3-ITD and NPM1 and CEBPA by PCR
FLT3-ITD and NPM1 by PCR
FLT3-ITD (semi-quant) by PCR
NPM1 (semi-quant) by PCR
CEBPA by PCR
CEBPA by sequencing
IDH1/2 sequencing
KIT sequencing
TP53 sequencing
BRAF for HCL and LCH by PCR
Acute Myeloid Leukemia (AML) & Related Precursor Neoplasms
Myeloproliferative Neoplasms/Myelodysplastic Syndromes
Paroxysmal Noctural Hemoglobinuria (PNH) Panel
Multiple Myeloma (MM) Panel
Molecular Studies
Patient’s Name:__________________________________ CellNetix Accession #/Consult Accessions:______________________
Patient’s Date of Birth:_____________________________ Original CellNetix Date of Service:_____________________________
ICD10:__________________________________________________Ordering Physician and Facility:______________________
Patient’s insurance information required for add-on testing
PLEASE PRINT CLEARLY
Date of Request:__________________________________
Fax: 206-215-5935 or 866-721-9696
Add-On Test Authorization - Hematopathology
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Add-On Test Authorization - Hematopathology Patients insurance information (CellNetix Pathology & Laboratories)

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Completed 12 August 2021

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