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?3356610-1619250Patient Name:_______________________________MRN#:_____________________________________DOB (MM/DD/YY):____________ Sex:________00Patient Name:_______________________________MRN#:_____________________________________DOB (MM/DD/YY):____________ Sex:________UCSF Clinical Cancer Genomics Laboratory RequisitionOrdering Date: Ordering Provider: NPI: Phone: Fax:Email:Address:Specimen InformationCase: Block: Tissue Type: Collection Date: Clinical Information: ICD10: ICD-10 code(s) is/are necessary for all test requests to indicate medical necessity, and for billing purposes. Complete the entire requisition to ensure prompt processing of test. Incomplete requisitions will NOT be processed.Test MenuInterpretation of each test by a laboratory physician will automatically be performed and billed for.BRAF Mutation IDH1 MutationFISH: 1p/19q Deletion EGFR MutationIDH2 MutationFISH: ALK Gene Rearrangement KRAS MutationKIT MutationFISH: BRAF Gene RearrangementHRAS Mutation TERT Promoter Mutation FISH: ETV6 Gene RearrangementNRAS Mutation Microsatellite Instability (MSI)FISH: EWSR1 Gene RearrangementFOXL2 Mutation MLH1 Promoter MethylationFISH: HER2 Gene Amplification GNAQ Mutation Hydatidiform Mole GenotypingFISH: MDM2 Gene AmplificationGNA11 Mutation Specimen Identity – Call the laboratory before ordering this test.FISH: SS18 (SYT) Gene RearrangementCommon Hereditary Cancer Panel. Requires signed patient consent or documentation in clinic note. Download the patient consent form from sending outside pathology materials, CCGL requires:For mutation or other PCR testing: 5 unstained slides, at 10 microns on uncharged slides. For FISH: 3 unstained slides per test (probe), cut at 4-5 microns on positively charged slides. An adjacent H&E stained slide.A copy of the pathology report.PLEASE SHIP MONDAY thru THURSDAY ONLY.Billing Information for UCSF (Check One Box)UCSF outpatient within 30 days of outpatient procedure or UCSF inpatient within 14 days of inpatient discharge.Bill patient’s insurance, authorization approvedNo authorization requiredSelf-pay, patient informedPatient Phone: Billing Information for outside InstitutionInstitutional BillingPhone: Address:Self-pay, patient informedPatient Phone: ................
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