2020 Babcock Rd, Suite 30 Immunohistochemistry and San Antonio, TX 78229 www.corepath.us Special Stains Requisition P 1.877.617.4445 | F 210.617.4457

REQUIRED ITEMS 1. Clinical Information 2. ICD 10 Codes 3. Face Sheet (Front and Back Copy of the Patient’s Insurance Card and Demographic Information) 4. Provider’s Signature

PATIENT INFORMATION PROVIDER INFORMATION

Last Name ______

First Name ______M.I. ______

DOB ______/______/______Gender: Male Female Other______

Address______Authorized Provider Signature Date

City State Zip ______Please Fax Duplicate Report to Additional Provider Fax Phone______Patient ID ______

BILLING INFORMATION

Bill to: Insurance Medicare Referring Facility (Hospital/Client) Split Billing - Client (TC) and Insurance (PC) Patient Patient Status: Inpatient (Hospital) Outpatient (Hospital) Non-Hospital ASC Prior Authorization # ______CLINICAL INFORMATION Indication(s) for Testing: ______ICD-10 Codes: ______

SPECIMEN INFORMATION Date Collected ______/______/______BREAST ONLY CELL BLOCKS Cold ischemic time < 1 hour? Yes No # of Blocks ______Time Collected ______:______AM PM Formalin fixation duration 6-72 hours? Yes No Tissue Type ______Date Retrieved ______/______/______TISSUE BLOCKS SLIDES Date Discharged ______/______/______# of Blocks ______# Stained ______Stain Type ______Specimen ID ______Tissue Type ______# Unstained ______

STAINS REQUESTED Please select service: Global TC DUAL/MULTIPLE HEMATOPATHOLOGY Please select service: Global TC ADH5 HBME1 Thyroglobulin STAINS ALK1 CD20 CD117/cKIT IgM Adrenocorticotropic HCG Beta Thyroid Stimulating A1 CD21 CD123 Ki67 (MIB1) Please select service: Hormone HepPar1 TTF1 BCL2 CD23 CD138 Lysozyme AE1/AE3 (Pan Cytokeratin) HMB45 Vimentin Global TC BCL6 CD25 CD163 MPO AFP HPL WT1 BOB1 CD30 Clusterin MUM1 Alpha 1-Antichymotrypsin IDH1 CDX2/CK7 BRAF V600E CD33 CXCL13 OCT2 Amyloid A Inhibin PD-L1’S E-/p120 C-MYC CD34 Cyclin D1/BCL1 OCT4 Amyloid A&P Panel INI1 p63/CK5/6 CD1a CD42b EMA PAX5 Amyloid P Insulin Please select service: PIN4 CD2 CD43 Fascin SOX11 ALK, D5F3 (Lung, FDA) Ki67 (MIB1) Global TC TFF1/Napsin A CD3 CD45 (LCA) Glycophorin A TCL1 LH Uro-2TM CD4 CD45RO Granzyme B TCR BetaF1 Arginase 1 Mammaglobin PD-L1 22C3 (FDA) (CK20/p53)/CD44 CD5 CD56 Hemoglobin A TdT B72.3 MART-1 (for KEYTRUDA®) CD7 CD57 IgA TIA1 Ber-Ep4 MDM2 Cervical CD8 CD61 IgD TRAP Beta Catenin Melan A INFECTIOUS DISEASE ESCC (Esophageal) CD10 CD68 IgG Tryptase CA125 Mesothelin Gastric/GEA Please select service: CD15 CD79a IgG4 CA19.9 MITF HNSCC (Head & Neck) MOC31 Global TC NSCLC Please select service: Global TC Calponin MYOD1 IN-SITU HYBRIDIZATION Urothelial Carcinoma CAM5.2 Myogenin Adenovirus CMV (ISH) EBER (ISH) HPV RNA (ISH) Kappa/Lambda CMV (IHC) Carbonic Anhydrase IX Myoglobin PD-L1 SP142 (FDA) CMV (ISH) (CA IX) Napsin A (for TECENTRIQ®) CYTOCHEMICAL STAINS Please select service: TC Only Calretinin NF () EBER (ISH) NSCLC H. Pylori Double Esterase Myeloperoxidase PAS Sudan Black B CD31 NSE TNBC (Breast) CD44 p16 HHV8 Urothelial Carcinoma HPV RNA (ISH) SPECIAL STAINS_ Please select service: TC Only CD99 p27 PD-L1 28-8 (FDA) CDK4 p40 HSV 1/2 AcP Elastic Stain Gram Stain Reticulin (for OPDIVO®) CDX2 p53 Parvovirus AFB FITE Iron Trichrome CDX2/CK7 Double Stain p57 Pneumocystis Alcian Blue Fontana Masson Mucicarmine Warthin Starry PD-L1 SP263 (FDA) Spirochete CEA (M) p63 (for IMFINZITM) Calcium Stain Giemsa PASD Wright Giemsa CEA (P) p120 Catenin Toxoplasma Colloidal Iron GMS PASF pHistone H3 (PHH3) Chromogranin A p504S VZV PTEN CK5/6 PAX8 Retinoblastoma HISTOLOGY SPECIAL INSTRUCTIONS CK7 PD1 GASTROINTESTINAL CK19 Perforin Protein (RB) CK20 PHH3 RRM1 Please select service: TOPO1 Collagen IV PLAP Global TC D240 Prolactin Thymidylate Synthase VEGF Desmin PSA Mismatch Repair Panel DOG1 PSAP (MLH1, MSH1, MSH2, E-Cadherin PSMA BREAST MARKERS PMS2) Factor VIII PTH Please select service: MLH1 Factor X111a RCC1 MSH1 FSH S100 Global TC MSH2 Gastrin GATA3 Serotonin ADH5 PMS2 GCDFP15 Smooth Muscle Actin E-Cadherin IN PROGRESS GFAP Somatostatin ER OTHER LABORATORY USE ONLY GH SOX10 Her-2 Breast Glucagon STAT6 Ki67 (MIB1) GLUT1 Surfactant Mammaglobin Glypican-3 Synaptophysin PR GE-FM-0640 Version 1.2 WHITE - COREPATH COPY YELLOW - CLIENT COPY