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Ship specimens to: Billing Information Mayo Clinic Laboratories • An itemized invoice will be sent each month. 3050 Superior Drive NW • Payment terms are net 30 days. Rochester, MN 55901 Call the Business Office with billing related questions: Customer Service: 855-516-8404 800-447-6424 (US and Canada) 507-266-5490 (outside the US) Visit www.MayoClinicLabs.com for the most up-to-date test and shipping information. T732 ©2021 Mayo Foundation for Medical Education and Research Page 1 of 4 MC0767-02Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No.

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ALZHEIMER’S DISEASE DEMENTIA EPILEPSY ADEVL Alzheimer’s Disease Evaluation, Autoimmune Dementia Autoimmune Epilepsy Spinal Fluid DMS2 Dementia, Autoimmune Evaluation, EPS2 Epilepsy, Autoimmune Evaluation, Serum APOEG Apolipoprotein E Genotyping, Blood Serum (NMDA, LGI1, CASPR2, AMPA, (NMDA, LGI1, CASPR2, AMPA, GABA, GABA, DPPX, mGluR1, PCA-Tr, IgLON5, DPPX, mGluR1, PCA-Tr, ANNA-1, ANNA-2, AUTOIMMUNE CNS AND ANNA-1, ANNA-2, ANNA-3, AGNA-1, ANNA-3, AGNA-1, PCA-2, CRMP-5, PARANEOPLASTIC DISORDERS PCA-2, CRMP-5, Amphiphysin, GAD65, Amphiphysin, GAD65, GFAP) GFA P, NIF ) ENS2 Encephalopathy, Autoimmune Evaluation, EPC2 Epilepsy, Autoimmune Evaluation, Spinal Serum (NMDA, LGI1, CASPR2, AMPA, DMC2 Dementia, Autoimmune Evaluation, Spinal Fluid (NMDA, LGI1, CASPR2, AMPA, GABA, DPPX, mGluR1, PCA-Tr, IgLON5, Fluid (NMDA, LGI1, CASPR2, AMPA, GABA, DPPX, mGluR1, PCA-Tr, ANNA-1, ANNA-1, ANNA-2, ANNA-3, AGNA-1, GABA, DPPX, mGluR1, PCA-Tr, IgLON5, ANNA-2, ANNA-3, AGNA-1, PCA-2, PCA-1, PCA-2, CRMP-5, Amphiphysin, ANNA-1, ANNA-2, ANNA-3, AGNA-1, CRMP-5, Amphiphysin, GAD65, GFAP) GAD65, GFAP, NIF) PCA-2, CRMP-5, Amphiphysin, GAD65, Hereditary Epilepsy GFA P, NIF ) ENC2 Encephalopathy, Autoimmune Evaluation, ESPAN Epilepsy/Seizure Genetic Panels by Next- Spinal Fluid (NMDA, LGI1, CASPR2, Creutzfeld Jakob Disease Generation Sequencing (NGS) AMPA, GABA, DPPX, mGluR1, PCA-Tr, NSESF Neuron-Specific Enolase (NSE), Select one subpanel from the list below. IgLON5, ANNA-1, ANNA-2, ANNA-3, Spinal Fluid AGNA-1, PCA-1, PCA-2, CRMP-5, Custom Gene Panel Frontotemporal Dementia Amphiphysin, GAD65, GFAP, NIF) Custom ID ______C9ORF C9orf72 Hexanucleotide Repeat, K11CS Kelch-Like Protein 11 Antibody, Early Epileptic Encephalopathy Panel (90 genes) Cell Binding Assay, Serum Molecular Analysis MAPT Gene, Sequence Analysis, Encephalopathy with Seizures Panel (129 genes) K11CC Kelch-Like Protein 11 Antibody, MAPTZ Cell Binding Assay, Spinal Fluid 7 Exon Screening Panel Epilepsy with Migraine Panel (7 genes) Progranulin Gene (GRN), PAVAL Paraneoplastic, Autoantibody Evaluation, GRNZ Epilepsy Expanded Panel (192 genes) Full Gene Analysis Serum (VGKC, VGCC-P/Q, Febrile Seizure Panel (9 genes) AChR Ganglionic, PCA-Tr, ANNA-1, ANNA-2, ANNA-3, AGNA-1, PCA-1, DEMYELINATING DISEASE Focal Epilepsy Panel (16 genes) PCA-2, CRMP-5, Amphiphysin) CDS1 CNS Demyelinating Disease Evaluation, Infantile Spasms Panel (17 genes) Serum (AQP4, MOG) PAC1 Paraneoplastic, Autoantibody Evaluation, Neuronal Migration Disorders Panel (29 genes) Spinal Fluid (PCA-Tr, ANNA-1, ANNA-2, NMOFS Neuromyelitis Optica (NMO)/ Progressive Myoclonic Epilepsy Panel (27 genes) ANNA-3, AGNA-1, PCA-1, PCA-2, Aquaporin-4-IgG Fluorescence-Activated CRMP-5, Amphiphysin) Cell Sorting (FACS) Assay, Serum Tuberous Sclerosis Panel (2 Genes) GD65S Glutamic Acid Decarboxylase (GAD65) MOGFS Myelin Oligodendrocyte Glycoprotein FOLLOW-UP TESTING - NEUROIMMUNOLOGY Antibody Assay, Serum (MOG-IgG1) Fluorescence-Activated Cell Sorting (FACS) Assay, Serum PNEFS Neuroimmunology Antibody Follow-up, GD65C Glutamic Acid Decarboxylase (GAD65) Serum Antibody Assay, Spinal Fluid KCSF Immunoglobulin Kappa Free Light Chain, Specify Antibody ______Pediatric CNS Disorders Spinal Fluid Multiple Sclerosis (MS) Profile, Serum PNEFC Neuroimmunology Antibody Follow-up, PCDEC Pediatric Autoimmune Central Nervous MSP3 Spinal Fluid System Disorders Evaluation, Spinal Fluid and Spinal Fluid (NMDA, LGI1, CASPR2, GABA, AQP4, Specify Antibody ______DPPX, MGIuR1, PCA-Tr, ANNA-1, GAD65, DEVELOPMENTAL DELAY GFAP) CMACB Chromosomal Microarray, Congenital, MENINGITIS Blood PCDES Pediatric Autoimmune Central Nervous CSFME Meningitis/Encephalitis Pathogen Panel, System Disorders Evaluation, Serum FXS Fragile X Syndrome, Molecular Analysis PCR, Spinal Fluid (NMDA, LGI1, CASPR2, GABA, AQP4, PWAS Prader-Willi/Angelman Syndrome, MOG, DPPX, MGIuR1, PCA-Tr, ANNA-1, Molecular Analysis HEREDITARY HEARING LOSS GAD65, GFAP) AudioloGene Hereditary Hearing Loss MECPZ MECP2 Gene, Full Gene Analysis HHLP Panel, Varies AUTOIMMUNE VISION LOSS DYSAUTONOMIA PVLE Paraneoplastic Vision Loss Evaluation, Serum (RCVBS, CRMS) DYS2 Autoimmune Dysautonomia Evaluation, Serum (LGI1, CASPR2, DPPX, AChR RCVBS Recoverin-IgG Antibody by Immunoblot, Ganglionic, ANNA-1, PCA-2, CRMP-5) Serum

T732 Page 2 of 4 MC0767-02Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No.

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MITOCHONDRIAL DISORDERS MYELOPATHY Motor Neuron Disease GDF15 Growth Differentiation Factor 15, Plasma MAS1 Autoimmune Myelopathy Evaluation, Serum Motor Neuron Disease Panel (17 genes) (AQP4, MOG, DPPX, mGluR1, PCA-Tr, MITOP Mitochondrial Full Genome Analysis Neuromuscular Junction by Next-Generation Sequencing (NGS) ANNA-1, ANNA-2, ANNA-3, AGNA-1, PCA-1, PCA-2, CRMP-5, Amphiphysin, Congenital Myasthenic Syndromes Panel MITON Mitochondrial Nuclear Gene Panel GAD65, GFAP, NIF) (25 genes) by Next-Generation Sequencing (NGS) MAC1 Autoimmune Myelopathy Evaluation, Hyperexcitable Muscle Disease MITOT Combined Mitochondrial Analysis, Spinal Fluid (AQP4, DPPX, mGIuR1, Skeletal Muscle Channelopathy Panel (6 genes) Mitochondrial Full Genome and Nuclear PCA-Tr, ANNA-1, ANNA-2, ANNA-3, DBMD Duchenne/Becker Muscular Dystrophy, Gene Panel AGNA-1, PCA-1, PCA-2, CRMP-5, DMD Gene, Large Deletion/Duplication Amphiphysin, GAD65, GFAP, NIF) MOVEMENT DISORDERS Analysis Autoimmune Movement Disorders NEUROMUSCULAR SMNDX Spinal Muscular Atrophy Diagnostic Assay, Deletion/Duplication Analysis GD65S Glutamic Acid Decarboxylase (GAD65) Autoimmune Neuromuscular Antibody Assay, Serum SBULB Spinal Muscular Atrophy Myopathy (Kennedy Disease), Molecular Analysis GD65C Glutamic Acid Decarboxylase (GAD65) NMS1 Necrotizing Myopathy Evaluation, Serum Antibody Assay, Spinal Fluid (HMGCR, SRP) NEUROPATHY GLYCS Glycine Receptor Alpha1 IgG, Cell Binding Multifocal Motor Neuropathy Autoimmune Neuropathy Assay, Serum GM1B Ganglioside Antibody Panel, Serum AIAES Autoimmune Axonal Evaluation, Serum GLYCC Glycine Receptor Alpha1 IgG, Cell Binding (Monosialo GM1, IgG; Monosialo GM1, (LGI1, CASPR2, ANNA-1, ANNA-3, Assay, Spinal Fluid IgM; Asialo GM1, IgG; Asialo GM1, IgM; AGNA-1, PCA-1, PCA-2, CRMP-5, K11CS Kelch-Like Protein 11 Antibody, GD1b, IgG; GD1b, IgM) Amphiphysin) Cell Binding Assay, Serum Sensory and Motor Neuropathy Hereditary Peripheral Neuropathy Kelch-Like Protein 11 Antibody, K11CC AIAES Autoimmune Axonal Evaluation, Serum PMPDD PMP22 Gene, Large Deletion/ Cell Binding Assay, Spinal Fluid (LGI1, CASPR2, ANNA-1, ANNA-3, Duplication Analysis Movement Disorder, Autoimmune AGNA-1, PCA-1, PCA-2, CRMP-5, MDS2 NPPAN Peripheral Neuropathy Genetic Panels by Amphiphysin) Evaluation, Serum (NMDA, LGI1, CASPR2, Next-Generation Sequencing (NGS), Blood DPPX, MGIuR1, VGCC-P/Q, PCA-Tr, MAGES Myelin Associated Glycoproteins (MAG) Select one subpanel from the list below. IgLON5, ANNA-1, ANNA-2, ANNA-3, Autoantibodies (IgM), Serum AGNA-1, PCA-1, PCA-2, CRMP-5, Custom Gene Panel Amphiphysin, GAD65, GRAF1, ITPR1, NIF) Hereditary Neuromuscular Custom ID ______MDC2 Movement Disorder, Autoimmune Neuromuscular Disorders Hereditary Motor Neuropathy Panel (23 genes) Evaluation, Spinal Fluid (NMDA, LGI1, NMPAN Neuromuscular Genetic Panels by Next- CASPR2, DPPX, MGIuR1, PCA-Tr, IgLON5, Generation Sequencing (NGS) Hereditary Sensory Neuropathy Panel (18 genes) ANNA-1, ANNA-2, ANNA-3, AGNA-1, Select one subpanel from the list below. Metabolic or Syndromic Neuropathies (74 genes) PCA-1, PCA-2, CRMP-5, Amphiphysin, GAD65, GRAF1, ITPR1, NIF) Custom Gene Panel Motor and Sensory Neuropathy Panel (82 genes) Hereditary Movement Disorders Custom ID ______Peripheral Neuropathy Expanded Panel (193 genes) DRPL Dentatorubral-Pallidoluysian Atrophy Distal Myopathy + Peripheral Neuropathy (DRPLA) Gene Analysis Distal Weakness Expanded Panel (217 genes) SEPT9 Gene, Full Gene Analysis (1 gene) FFRWB Friedreich Ataxia, Frataxin, Quantitative, Myopathies Spastic Paraplegia Neuropathy Panel (41 genes) Whole Blood Myopathy Expanded Panel (141 genes) SLEEP DISORDERS HAD Huntington Disease, Molecular Analysis Muscular Dystrophy Panel (77 genes) ORXNA Orexin-A/Hypocretin-1, Spinal Fluid MYASTHENIA GRAVIS Congenital Myopathy Panel (36 genes) MGMR Myasthenia Gravis Evaluation with Metabolic Myopathy Panel (41 genes) Muscle-Specific Kinase (MuSK) Reflex, Serum Myofibrillar Myopathy Panel (12 genes) MGLE Myasthenia Gravis/Lambert-Eaton Distal Myopathy Panel (27 genes) Myasthenic Syndrome Evaluation, Serum Emery-Dreifuss Panel (5 genes) Stand-Alone Antibodies Rhabdomyolysis and Myopathy Panel (31 genes) ARBI Acetylcholine Receptor (Muscle AChR) Binding Antibody, Serum MUSK Muscle-Specific Kinase (MuSK) Autoantibody, Serum

T732 Page 3 of 4 MC0767-02Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No.

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THERAPEUTIC TESTING / DRUG MONITORING ADDITIONAL TESTS Antiepileptic Drugs (INDICATE TEST NUMBER AND NAME) AMOBS Amobarbital, Serum CARTA Carbamazepine, Total, Serum CDP Chlordiazepoxide and Metabolite, Serum DIA Diazepam and Nordiazepam, Serum ETX Ethosuximide, Serum FELBA Felbamate (Felbatol), Serum GABA Gabapentin, Serum LACO Lacosamide, Serum LAMO Lamotrigine, Serum LEVE Levetiracetam, Serum OMHC Oxcarbazepine Metabolite, Serum PBR Phenobarbital, Serum PNYA Phenytoin, Total, Serum PRMB Primidone and Phenobarbital, Serum SECOS Secobarbital, Serum TOPI Topiramate, Serum VALPA Valproic Acid, Total, Serum ZONI Zonisamide, Serum Pharmacogenomics PGXQP Focused Pharmacogenomics Panel (CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, SLCO1B1, VKORC1, CYP4F2, and rs12777823) COMTQ Catechol-O-Methyltransferase (COMT) Genotype 1A2Q Cytochrome P450 1A2 Genotype 2C19R Cytochrome P450 2C19 Genotype 2C9QT Cytochrome P450 2C9 Genotype 2D6Q Cytochrome P450 2D6 Comprehensive Cascade 3A4Q Cytochrome P450 3A4 Genotype 3A5Q Cytochrome P450 3A5 Genotype TPNUQ Thiopurine Methyltransferase (TPMT) and Nudix Hydrolase (NUDT15) Genotyping WARSQ Warfarin Response Genotype

T732 Page 4 of 4 MC0767-02Arev0721