IHCIHC RequisitionRequisition

2580 Westside2580 W Parkway,estside Alpharetta,Parkway, Alpharetta, GA 30004 GA 30004 DateDat packaged:e Packaged / / P: 1-800-459-1185PH 1-800-459-1185 | F: 1-888-809-9071 FAX 1-888-809-9071 CLIENT IDENTIFICATION PATIENT IDENTIFICATION CLIENT IDENTIFICATION PATIENT IDENTIFICATION Last Name: Last Name FiFirstrst Name: Name Middle InitiaMiddlel Initial:

Gender: M F DOB: Age: MPN: Address City State ZIP Ordering Physician: Treating Physician: INSURANCE / BILLINGDOB INFORMATION Age Gender SSN Phone REQUIRED: Please include face sheet and front/back of patient’s insurance card. M/F Bill to: Client bill Insurance Patient/Self Pay Split Bill: Client (TC) and Insurance (PC)

OP Molecular to Medicare Bill charges to other hospital/facility: Ord ering Phy sici an MR N Account Name & C-Number Prior Authorization Number: Treating Physician Specimen ID SPECIMEN INFORMATION (Two unique identifiers are required on requisition & specimen) * Specimen ID: Select Best Block BIHospitalLLIN statusG IN whenFORM specimenAT collected:ION INSURANCE INFORMATION  Attached face sheet/insurance  Self  Spouse  Child  Other B l ill to: Hospital C Inpatientient  I ns ur Hospitalance Outpatient Patient Non-Hospital Medicar eOutreach # / Clinic Patient Body Site:Medicaid #  Pre-Authorization #  Primary Ins. INSURER POLICY # GROUP #  Secondary Ins. INSURER POLICY # GROUP # Formalin Fixed: Yes No Other Fixation: SPIDC-10ECIM Code(s):EN INFORMATION ICD-10 Code(s): Tw(ICD-10o u niinformationque identi is required)fiers are required on requisition & specimen Cold Ischemia(ICD-10 Time informa (min):tio n is required) Fixation Time (hours): Hospital status when specimen collected: BoCollectiondy Site Date: Time: Date of Discharge: Block(s): Slides: Other:  Formalin Fixed  Other Fixation  Hospital Inpatient  Hospital Outpatient  Non-Hospital Outreach/Clinic Patient LEVEL OF SERVICE (REQUIRED - Please choose one): Global (with interpretation) Slide COnlyollection (TC): glass Da slideste only Web-Enabled (TC):Tim digitale images through e.CSI™ Cold Ischemia Time (min) Fixation Time (hours) Date of Discharge  ABN is available  A-1-ACTBlock(s) #  SlidCD163e(s) #  OtheChymotrypsinr # Glucagon Lambda by ISH p57 TCL1 A-1-AT CD19 CMV Glycophorin A (CD235) Date PLEF-1ulled from Archive p63 TdT ACTH CD1a c-MYC REQUESTEDGlypican-3 TESTINLH G Pan-Melanoma (HMB45/ Thrombomodulin Adenovirus CD2 CK14 Granzyme B Lysozyme (Muramidase) Melan-A/Tyrosinase) Thyroglobulin LEVEL OF SERVICE:  Global (with interpretation)  Slide Only (TC): glass slides only  Web-Enabled (TC): digital images through e.CSI™ AE1 CD20 (L26) CK17 H. Pylori Mammaglobin Parvovirus B19 TIA-1  A-1-ACT  CD23  CK903  hMLH-1  Napsin A  Serotonin AE1/AE3 CD21 CK19 LABORATORYHBcAg TEST REQUMART-1ESTED PAX-2 Toxoplasma Gondii  A-1-AT  CD25  D2-40 (Podoplanin)  hMSH-2  NF  SMM-HC AFP CD22 CK20 HBME-1 MDM2 PAX-5 TRAcP  ACTH  CD3  DBA-44  hMSH-6  NSE  SMA ALK-1 (5A4) CD23 CK5/6 HBsAg Melan-A PAX-8 Treponema Pallidum  Adenovirus  CD30 (Ber-H2)  Desmin  hPL  NY-BR-1  Somatostatin  AE1Amyloid A CD25 CD31 CK7  DOG-1 HCG  HSV I/IIMesothelin  OCT-2PCP (Pneumocystis)  SOX-10Trypsin  AE1/AE3Annexin 1 CD3  CD33 CK8  E-cadherin Hemoglobin A  IgA Micrometastases (CK8/18)  OCT-3/4PD-1  SOX-11Tryptase (Mast Cell)  AFPAR (Androgen Rec.) CD30 (Ber-H2)CD34 CK8/18  EBER by ISH Hepatocyte (HepPar -1)  IgD Mismatch Repair (MLH1/  p120 PD-L1 SP263 (Imfinzi®)  SurfactantTSH Apoprotein A  ALK-1Arginase-1 (5A4) CD31 CD38 CK903  EBV LMP HER2  IgE MSH2/MSH6/PMS2)  p16 (CINtec)PD-L1 SP142 (Tecentriq®)  SynaptophysinTTF-1  AmyloidATRX A CD33 CD4 D2-40 (Podoplanin) EGFR by IHC HHV-8  IgG (p) MOC-31  p21 (WAF1)PD-L1 22c3 (Keytruda®)  TdTTyrosinase  Annexin 1  CD43  EMA  IgG4(m) + IgG(p)  p27  Thrombomodulin B72.3 (TAG72) CD34 DBA-44 HLA-DR MPO PHH3 Uroplakin II  AR (Androgen Rec.)  CD44  Epi/Myoepithelial Cktl (EMEC)  IgM  p40  Thyroglobulin BCL-1 (Cyclin D1) CD38 Desmin HMB-45 MSA (Muscle Specific Actin) Villin  Arginase-1  CD45 (LCA) (CK5+CK14+p63; Red CK8/18)  Inhibin  p504SProstate (AMACR) Triple Stain  TIA-1 BCL-2 CD4 DOG-1 hMLH-1 MUC1 (CK903+p63; Red p504S) VImentin  B72.3 (TAG72)  CD45RO (UCHL-1)  ER  INI-1  p53  Toxoplasma Gondii BCL-6 CD43 E-cadherin hMSH-2 MUC2 VIP  BCL-1 (Cyclin D1)  CD5  Factor VIII  Insulin  p57 PLAP  TRAcP  BCL-2Ber-EP4 CD44 CD56 (NCAM) EBER by ISH  Factor XIIIa hMSH-6  Kappa byMUC4 IHC  p63 PMS2  TreponemaVZV (Varicella Pallidum Zoster)  BCL-6Beta-Catenin CD45 (LCA)CD57 EBV LMP  Fascin hPL  Kappa/LambdaMUC5AC Double Stain  Pan-MelanomaPR  TrypsinWT-1 (N-terminus)  Ber-EP4BG8 (Lewis Y) CD45RO (UCHL-1)CD61 EGFR  Fli-1 HSV I/II  Kappa byMUC6 ISH (HMB45/Melan-A/Tyrosinase)Prolactin  TryptaseZAP-70 (Mast Cell)  Beta-CateninBOB-1 (B Cell Specific CD5  CD68 EMA  FOXp3 IgA  Ki-67 MUM-1  ParvovirusPSA B19 SPECIALTSH STAINS BG8Octamer (Lewis Binding) Y)  CD56 (NCAM)CD7 Epi/Myoepithelial CktlFSH (EMEC) IgD  Ki-67 + MyoD1CD138 Double Stain  PAX-2PSAP  TTF-1AFB  CAIXCAIX CD57 CD71 (CK5+CK14+p63;Red CK7/18)Galectin-3 IgE  LambdaMyogenin by IHC  PAX-5PTH  TyrosinaseAlcian Blue (pH2.5)  CA 125  CD79a  Gastrin  Lambda by ISH  PAX-8  Uroplakin II CA 125 CD61 ER IgG (p) Napsin A RCC (PNRA) Alcian Blue + PAS  CA 19.9  CD8  GATA-3  LH  PCP (Pneumocystis)  Villin CA 19.9 CD68 Factor VIII IgG4+IgG NF S100 Colloidal Iron  Calcitonin  CD99  GCDFP-15  Lysozyme (Muramidase)  PD-1  Vimentin Calcitonin CD7 Factor Xllla IgM NSE S100p Congo Red  Caldesmon  CDK4 by IHC  GFAP  Mammaglobin  PD-L1 (Avail. Only as Global)  VIP  CalponinCaldesmon CD71 CDX2 Fascin  GH Inhibin  MART-1NY-BR-1  PHH3SALL4  VZVEVG (Varicella - Elastic Zoster)  CalretininCalponin CD79A CEA (m) Fli-1  Glucagon INI-1  MDM2 byOCT-2 IHC  ProstateSATB2 Triple Stain  WT-1GMS (N-terminus) (Fungus)  CAMCalretinin 5.2 CD8  CEA (p) FOXp3  Glycophorin AInsulin (CD235)  Melan-AOCT-3/4 (CK903+p63;Serotonin Red p504S)  ZAP-70Gram  CD10CAM 5.2(CALLA) CD99 Chromogranin A FSH(m)  Glypican-3 Kappa  Mesothelinp120  PLAPSMM-HC Iron CD117 (c-KIT)  CD10 (CALLA) CDK4 Chromogranin A Galectin-3(p)  Granzyme B Kappa/Lambda IHC  Micrometastasesp16 (CINtec) (CK8/18)  PMS2SMA Mucicarmine  CD11cCD117 (c-KIT) CDX2 Chymotrypsin Gastrin  H. Pylori Double Stain  MOC-31p21 (WAF1)  PP (PancreaticSomatostatin Polypeptide) PAS without diastase  CD123  CMV  HBcAg (Hepatitis B Core Antigen)  MPO  PR CD11c CEA (m) GATA-3 Kappa by ISH p27 SOX-10 PAS with diastase  CD138  c-MYC  HBME-1  MSA (Muscle Specific Actin)  Prolactin CD123 CEA (p) GCDFP-15 Ki-67 p40 SOX-11 IMAGE ANALYSISReticulin  CD15 (LeuM1)  CK14  HBsAg  MUC1  PSA CD138 Chromogranin A (m) GFAP Ki-67/CD138 IHC Double Stain p504S (AMACR) STAT-6 Steiner  CD163  CK17  HCG  MUC2  PSAP  ER  PR  HER2  Ki-67  p53  CD19CD15 (LeuM1) Chromogranin CK19 A (p) GH  Hemoglobin ALambda  MUC4 p53  PTH SynaptophysinADD’L TESTINGTrichrome(Global) Wright-Giemsa  CD1a  CK20  Hepatocyte (HepPar -1)  MUC5AC  RCC (PNRA)  HER2 FISH  TOP2A FISH  CD2  CK5/6  HER2 by IHC  MUC6  S100  DNA Ploidy by Flow  TFE3 by FISH ADDITIONAL CD20 (L26) TESTS, COMMENTS ORCK7 DIFFERENTIAL DIAGNOSIS HHV-8  MUM-1PROGNOSTIC  S100p  CD21  CK8  HLA-DR  MyoD1Image Analysis Global  S ALL Image4 Analysis HETechnicalR2/D1 7 S1 2 2 b ySlide FIS HOnly  CD22  CK8/18  HMB-45  MyogeninER PR  HER2SATB 2 Ki-67 MDM2 by FISH p53  SS18 by FISH Additional Tests, Comments, or Differential Diagnosis For global HER2 IHC with results 2+, CSI will add HER2 FISH unless marked Physician Notice: Only tests or diagnostic services that are medically necessary should be ordered. Appropriate ICD-10 information must be provided in the specified area above. Do Not Reflex 2+ Payors, including Medicare and Medicaid, generally do not pay for screening tests. ADDITIONAL TESTING Authorized Signature HER2 FISH Global Tech-Only DNA Ploidy Global

CPhysicianSI Labo ratoNotice:ries UseOnly Onltestsy or diagnostic services that are medically necessary should be ordered. Appropriate ICD-10 information must be in the specified area above. Original and Second Copy (White / Canary) CSI Laboratories Payers,Or includingiginal and MedicareSecond Copy and Medicaid, (White /C generallyanary) - CSI do Lnotab oratpayor fories screening tests. Bottom Copy (Pink) - Client BottomPAC0 Copy08- (Pink)01/09 -/19 Client CSI_041520_R27 PLEASE CALL CSI CLIENT SERVICES AT (800) 459-1185 TO INQUIRE ABOUT TESTS NOT LISTED ON REVERSE

SPECIMEN REQUIREMENTS SHIP SPECIMENS WITH COLD PACK FISH* Formalin-Fixed Paraffin-Embedded Tissue Minimum 0.2 x 0.2 x 0.2 cm tissue; non-decalcified tissue only (FISH only). IHC 1 H&E slide with its corresponding paraffin block (10% neutral buffered formalin) - Preferred.

*For tech-only services, include 1 marked H&E slide (all at 4 microns). MUST CIRCLE AREA OF INTEREST ON H&E SLIDE.

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