Geneveda - Division of Genetics & Oncology 2439 Kuser Road • Hamilton, NJ 08690-3303 • • • • • • • (609) 570-1000 • Fax (609) 245-7665 Toll Free (877) 269-0090 www.geneveda.com Psychotropic & Neurological Pharmacogenomics Test Requisition Form Ordering Physician/Laboratory Test Selection - Testing performed by Next Generation Sequencing (Required: Include the ordering physician’s first & last name, NPI, practice name, complete PSYCHOTROPIC PHARMACOGENOMIC TESTING address, phone number and fax number.) 3401  Addiction to Alcohol, Cocaine, Heroin, Opioids, Tobacco - Anti-addiction (Nicotine), Anti-addiction (Opioids), Buprenorphine, Bupropion, Ethanol, Disulfiram, Heroin, Levodopa, Methadone, Naloxone, Naltrexone, Nicotine, Suboxone (ABCB1, ANKK1, COMT, CYP2B6, CYP2C19, CYP2D6, CYP3A4, DBH, MTHFR, OPRM1) 3404  Anxiety, Insomnia, Severe Agitation - Bupropion, Desvenlafaxine, Dexmedetomidine, Duloxetine, Escitalopram, Lorazepam, Midazolam, Oxazepam, Venlafaxine, Vilazodone (ABCB1, ADRA2A, ANKK1, COMT, CYP2C19, CYP2D6, CYP3A4, CYP3A5, GABRP, HTR2A, UGT1A1, UGT2B15) 3406  Bipolar Disorder - Aripiprazole, Lamotrigine, Lithium, Olanzapine, Oxcarbazepine, Quetiapine, Valproic acid, Vilazodone (ABCB1, ABCG2, ANKK1, CYP1A2, CYP2C9, CYP2D6, CYP3A4, CYP3A5, COMT, DRD1, GABRA6, HTR2A, MTHFR, UGT1A1, UGT2B7) 3407  Depressive Disorder and Major Depressive Disorder - Amitriptyline, Antidepressants (gen), Antipsychotics (gen), Aripiprazole, Bupropion, Citalopram, Clomipramine, Desipramine, Desvenlafaxine, Diazepam, Doxepin, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Imipramine, Maprotiline, Milnacipran, Mirtazapine, Nortriptyline, Olanzapine,Opipramol, Paroxetine, Quetiapine, Sertraline, SSRIs (gen), Trimipramine, Vilazodone, Venlafaxine, Vortioxetine (ABCB1, ADRA2A, ANKK1, COMT, CYP1A2, CYP2B6, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, DRD4, GABRP, GRIK4,HTR2A, HTR2C, MTHFR, UGT1A1) Physician to receive additional result report: 3412  Post-Traumatic Stress Disorder (PTSD) - Aripiprazole, Amitriptyline, Physician’s Signature: Date: Bupropion, Buspirone, Desvenlafaxine, Dronabinol, Duloxetine, Fluoxetine, Patient Information (Please Print) Fluvoxamine, Guanfacine, Hydroxyzine, Ketamine, Lamotrigine, Mirtazapine, Name (Last, First) (Required): Nefazodone, Paroxetine, Propranolol, Quetiapine, Risperidone, Sertraline, Trazodone, Valproic Acid, Venlafaxine, Vilazodone, Zolpidem (ABCB1, ABCG2, In Care of: ANKK1, COMT, CYP1A2, CYP2B6, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, DRD1, GABRP, HTR2A, UGT1A1, UGT2B7) Patient Address: 3410  Schizophrenia - Antipsychotics (gen), Aripiprazole, Chlorpromazine, Clozapine, City: State: Zip: Fluphenazine, Haloperidol, Iloperidone, Nemonapride, Olanzapine, Quetiapine, Risperidone, Thioridazine, Trifluoperazine, Zuclopenthixol (ABCB1, ANKK1, COMT, Gender (Required): o Female o Male Date of Birth (Required): CYP1A2, CYP2C9, CYP2D6, CYP3A4, CYP3A5, DRD1, HTR2A, HTR2C, MTHFR) Patient SS#: Patient ID#: 3202  Sedatives & Relaxants, including muscle relaxants - Carisoprodol, Phone Number: Dextromethorphan, Midazolam, Propofol, Rocuronium, Tolperisone (CYP2B6, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, SLCO1B1) Email: Billing Information (Please include a copy of the front & back of card.) NEUROLOGICAL PHARMACOGENOMIC TESTING o Relation (Required): Diagnosis Codes (Required): Patient Billing 3402  ADD/ADHD-Atomoxetine, Bupropion, Dextroamphetamine, Imipramine, o Insurance Billing o Self Please provide ALL applicable diagnosis codes. o o Spouse ______Methylphenidate, Modafinil, Nortriptyline (ANKK1, ABCB1, ADRA2A, CYP2B6, Path Lab/Hospital CYP2C19, CYP2D6, DRD1) o Physician Account o Dependant ______3405  Autism Spectrum Disorders - Aripiprazole, Quetiapine, Risperidone (ABCB1, Primary Insurance Carrier: ANKK1, COMT, CYP2D6, CYP3A4, CYP3A5, HTR2A) Insured’s Name (if not patient): 3403  Alzheimer’s Disease - Donepezil, Galantamine, Olanzapine, Risperidone Insured’s SS#: Insured’s DOB: (ABCB1, ANKK1, CYP1A2, CYP2C9, CYP2D6, CYP3A5, HTR2A, MTHFR) 3408  Epilepsy - Antiepileptics (gen), Brivaracetam, Carbamazepine, Clobazam, Claims Address: Lamotrigine, Mephenytoin, Oxcarbazepine, Phenobarbital, Phenytoin, Medicare, Medicaid or Policy ID#: Valproic acid (ABCB1, ABCG2, ANKK1, CYP1A2, CYP2C19, CYP2C9, CYP3A4, CYP3A5, GABRA6, UGT2B7) Employer/Group Name: Group#: 3411  Fibromyalgia - Amitriptyline, Atomoxetine, Bupropion, Carbamazepine, Specimen Information Carisoprodol, Codeine, Desipramine, Desvenlafaxine, Dextromethorphan, Date Collected (Required): Specimen Source: Duloxetine, Escitalopram, Fluoxetine, Milnacipran, Naltrexone, Nortriptyline,  Whole Blood  Saliva Prednisone, Quetiapine, Tramadol, Venlafaxine, Vilazodone (ABCB1,ADRA2A, ANKK1, COMT, CYP1A2, CYP2B6, CYP2C19, CYP2D6, CYP3A4, CYP3A5, Confirmation of Informed Consent and Medical Necessity for DBH, GABRP, HTR2A, OPRM1, UGT1A1, UGT2B7) Pharmacogenomic Genetic Testing My signature below certifies that I am a licensed medical professional or his/her representative or a genetic 3201  Pain Management - General - Alfentanil, Buprenorphine Codeine, Fentanyl, counselor authorized to order genetic testing. My signature further acknowledges the patient has been Hydrocodone, Ketamine, Lornoxicam, Methadone, Morphine, Opioids, supplied information regarding genetic testing and has been informed about the purpose, limitation and possible risks. The patient has been given the opportunity to ask questions about this consent and seek Oxycodone, Sumatriptan, Tramadol (ABCB1, COMT, CYP2B6, CYP2C9, outside genetic counseling. CYP2D6, CYP3A4, DBH, OPRD1, OPRM1) In the event that the patient’s health insurance plan determines for the test(s) I checked above that some of the genes that I requested for analysis are not covered, I understand that Medical Diagnostic Laboratories, 3409  Parkinson’s Disease - Entacapone (COMT) L.L.C. shall perform and result the test(s) for the genes I selected, then submit the claim to the patient’s health insurance plan for the testing of the genes covered under the patient’s plan. If the testing is covered by the patient’s health plan and the out-of-pocket expense is less than $150.00, testing will proceed without further delay or additional contact. The patient has given consent for genetic Other Tests/Panels: testing to be performed and the signed consent form is being provided with this requisition. I confirm that For a complete list of testing, please visit our website www.mdlab.com this testing is medically necessary for the specified patient and that these results will be used in the medical management and treatment decisions for this patient. Physicians must only order tests that they have determined are medically necessary for the diagnosis and treatment of a patient. MDL offers individual tests, as well as a limited number of customized panels. If you choose to order a panel, please make certain that each and every test is medically necessary. If you check off a panel as your choice, MDL understands that the physician has Medical Professional Signature (Req.):______Date: ______determined that all of the component tests are medically necessary, and will perform, report and bill for all such component tests. Must submit a completed Informed Consent Form Rel: 10/2019 Note: This Test Requisition Form must be submitted with a Patient Informed Consent/Insurance Acknowledgment Form Tests by Drug 3803 o Alfentanil 3833 o Clozapine 3880 o Galantamine 3917 o Mirtazapine 3952 o Propranalol 3804 o Allopurinol 3834 o Codeine 4028 o Guanfacine 3919 o Modafinil 3954 o Quetiapine 3805 o Amitriptyline 3843 o Desipramine 3883 o Haloperidol 3920 o Morphine 3958 o Risperidone 4001 o Antiaddiction -Nicotine 4033 o Desvenlafaxine 4015 o Heroin 3921 o Naloxone 3963 o Sertraline 4002 o Antiaddiction -Opioids 3845 o Dexmedetomidine 3884 o Hydrocodone 3922 o Naltrexone 3968 o SSRIs (gen) 4003 o Antidepressants (gen) 3846 o Dextroamphetamine 4029 o Hydroxyzine 4030 o Nefazodone 4023 o Suboxone 3808 o Antiepileptics (gen) 4009 o Dextromethorphan 3887 o Iloperidone 3924 o Nemonapride 3972 o Sumatriptan 3809 o Antipsychotics (gen) 3847 o Diazepam 3889 o Imipramine 3926 o Nicotine 3979 o Thioridazine 3810 o Aripiprazole 3851 o Disulfiram 3893 o Ketamine 3929 o Nortriptyline 3984 o Tramadol 3813 o Atomoxetine 3854 o Donepezil 3895 o Lamotrigine 3930 o Olanzapine 4031 o Trazodone 4007 o Brivaracetam 3855 o Doxepin 3899 o Levodopa 3934 o Opioids (gen) 3985 o Trifluoperazine 4008 o Buprenorphine 4027 o Dronabinol 3900 o Lithium 3935 o Opipramol 3986 o Trimipramine 3817 o Bupropion 4011 o Duloxetine 3902 o Lorazepam 3938 o Oxazepam 3988 o Valproic acid 4026 o Buspirone 3859 o Entacapone 3903 o Lornoxicam 4020 o Oxcarbazepine 3990 o Venlafaxine 3820 o Carbamazepine 3862 o Escitalopram 3906 o Maprotiline 3939 o Oxycodone 4034 o Vilazodone 3822 o Carisoprodol 4013 o Ethanol 3907 o Mephenytoin 3940 o Paclitaxel 3994 o Vortioxetine 3826 o Chlorpromazine 3867 o Fentanyl 3909 o Methadone 3942 o Paroxetine 4032 o Zolpidem 3829 o Citalopram 3873 o Fluoxetine 3911 o Methylphenidate 3943 o Phenobarbital 3999 o Zuclopenthixol 3830 o Clobazam 3874 o Fluphenazine 3915 o Midazolam 3945 o Phenytoin 3831 o Clomipramine 3877 o Fluvoxamine 3916 o Milnacipran 3950 o Prednisone

Commonly Used ICD-10 Diagnosis Codes for Medical Diagnostic Laboratories, L.L.C. Tests Please indicate your Diagnosis Code selection on the front of this test requisition in the designated spaces under “Billing Information – Diagnosis Codes (Required)”. This is a general, non-comprehensive guide for use by the healthcare provider to assist in the assignment of a diagnosis code to the laboratory testing ordered. The healthcare clinician must only order tests determined to be medically necessary for the diagnosis and treatment of the patient. ICD-10 Description ICD-10 Description F02.80 Dementia without behavioral disturbance F33.2 Major Depressive Disorder, recurrent, moderateMajor Depressive F10.20 Alcohol Dependence uncomplicated F33.3 Disorder, recurrent, severe, without psychotic features Major F10.229 Alcohol Dependence, with intoxication, unspecified disorder, F33.4 Depressive Disorder, recurrent, severe, with psychotic features unspecified F33.5 Major Depressive Disorder, recurrent, in partial remission F10.239 Alcohol Dependence, with withdrawal, unspecified F33.8 Major Depressive Disorder, recurrent, in full remission F10.24 Alcohol Dependence, with alcohol-induced mood disorder F33.9 Other recurrent depressive disorders F10.259 Alcohol Dependence, with alcohol-induced psychotic disorder, Major Depressive Disorder, single episode, unspecified Social unspecified F40.11 Phobia, generalized F10.29 Alcohol Dependence, with unspecified alcohol-induced disorder F40.9 Phobic Anxiety Disorder, unspecified F11.20 Opioid Dependence uncomplicated F41.1 Generalized Anxiety Disorder F11.229 Opioid Dependence with intoxication, unspecified F41.3 Other Mixed Anxiety Disorders F11.23 Opioid Dependence, with withdrawal F41.8 Other specified Anxiety Disorders F11.24 Opioid Dependence, with opioid-induced mood disorder F41.9 Anxiety Disorder, unspecified F11.259 Opioid Dependence with opioid-induced psychotic disorder, F43.10 PTSD, unspecified unspecified F43.11 PTSD, acute F14.20 Cocaine Dependence, uncomplicates F43.12 PTSD, chronic F14.23 Cocaine Dependence, with withdrawal F43.20 Adjustment Disorder, unspecified F14.29 Cocaine Dependence, with unspecified cocaine-induced disorder F43.21 Adjustment Disorder, with depressed mood F17.200 Nicotine Dependence, uncomplicated F43.22 Adjustment Disorder with anxiety F17.203 Nicotine Dependence, unspecified, with withdrawal F43.23 Adjustment Disorder with mixed anxiety and depressed mood F20.9 Schizophrenia, unspecified F43.8 Other Reactions to Severe Stress F31.10 Bipolar Disorder, current episode manic without psychotic F43.9 Reaction to Severe Stress, unspecified features, unspecified F51.5 Nightmare Disorder F31.19 Bipolar Disorder, unspecified F84.0 Autistic Disorder F31.2 Bipolar Disorder, current episode manic severe with psychotic F84.3 Other childhood disintegrative disorder features F84.9 Pervasive developmental disorder, unspecified F31.30 Bipolar Disorder, current episode depressed, unspecified F90.0 Attention-Deficit Hyperactivity Disorder, predominantly inattentive F31.4 Bipolar Disorder, current episode depressed, severe, without F90.1 Attention-Deficit Hyperactivity Disorder, predominantly hyperactive psychotic features F90.2 type F31.5 Bipolar Disorder, current episode depressed, severe, with F90.8 Attention-Deficit Hyperactivity Disorder, combined type psychotic features F90.9 Attention-Deficit Hyperactivity Disorder, other type F31.60 Bipolar Disorder, current episode mixed, unspecified G20 Attention-Deficit Hyperactivity Disorder, unspecified type F31.63 Bipolar Disorder, current episode severe, without psychotic G30.0 Parkinson’s Disease F31.64 episodes G30.1 Alzheimer’s Disease with early onset F31.70 Bipolar Disorder, current episode severe, with psychotic episodes G30.9 Alzheimer’s Disease with late onset Bipolar Disorder, currently in remission, most recent episode G40.901 Alzheimer’s Disease, unspecified F32.0 unspecified. G40.909 Epilepsy, unspecified, not intractable, with status epilepticus F32.1 Major Depressive Disorder, single episode, mild G40.911 Epilepsy, unspecified, not intractable, without status epilepticus F32.2 Major Depressive Disorder, single episode, moderate G40.919 Epilepsy, unspecified, intractable, with status epilepticus Major Depressive Disorder, single episode, severe, without G89.0 Epilepsy, unspecified, intractable, without status epilepticus F32.3 psychotic features G89.29 Central Pain Syndrome Major Depressive Disorder, single episode, severe, with psychotic G89.4 Other Chronic Pain F32.4 features M79.9 Chronic Pain Syndrome F32.5 Major Depressive Disorder, single episode, in partial remission Z79.891 Soft Tissue Disorder, unspecified (Fibromyalgia) F32.9 Major Depressive Disorder, single episode, in full remission Z81.8 Long Term (Current) use of Opiate Analgesic F33.0 Major Depressive Disorder, recurrent, unspecified Family History of other mental and behavioral disorders F33.1 Major Depressive Disorder, recurrent, mild