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MCL Internal Use Only Note: It Is the Client’S Responsibility to Maintain Documentation of the Order Neurology Specialty Testing Client Test Request Client Information (required) Patient Information (required) Client Name Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Phone Client Order No. Sex Birth Date (mm-dd-yyyy) Male Female Address Collection Date (mm-dd-yyyy) Time am pm City State ZIP Code Street Address City State ZIP Code Submitting Provider Information (required) Submitting/Referring Provider (Last, First) Phone Fill in only if Call Back is required. (required) Phone (with area code) Fax (with area code) Reason for Testing Provider’s National I.D. (NPI) *Fax number given must be from a fax machine that complies with applicable HIPAA regulation. “I hereby confirm that informed consent has been signed by an ICD-10 Diagnosis Code individual legally authorized to do so and is on file with this office or the individual’s provider’s office.” Note: It is the client’s responsibility to maintain documentation of the order. New York State Patients: Informed Consent for Genetic Testing Signature MCL Internal Use Only Note: It is the client’s responsibility to maintain documentation of the order. 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. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy) 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. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy) 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
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