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X X Cardiovascular Test Requisition X Cardiovascular Test Requisition Please attach detailed medical records, insurance card front/back, and clinical information to the requisition form. PRIMARY PATIENT ORDER PROVIDER LAST NAME FIRST NAME INSTITUTION/PRACTICE NAME INSTITUTION PHONE/FAX/EMAIL DATE OF BIRTH (MM/DD/YYYY) GENETIC SEX PROVIDER LAST NAME PROVIDER FIRST NAME Male Female Unknown MED REC#/PATIENT IDENTIFIER ETHNICITY NPI (USA) MINC (CANADA) PROVIDER TITLE (MD, DO, GC) ADDRESS PROVIDER ADDRESS CITY STATE/PROVINCE POSTAL CODE COUNTRY CITY STATE/PROVINCE POSTAL CODE COUNTRY PHONE EMAIL PROVIDER PHONE FAX REPORT TO SAMPLE DRAW DATE (MM/DD/YYYY) SAMPLE TYPE Blood Buccal Other: GC/PRIMARY CONTACT GC/PRIMARY CONTACT PHONE/EMAIL/FAX Extracted DNA & DNA Source: (Blood, Buccal, Tissue, Fibroblast) I have read the Informed Consent document and I give permission to Claro Lab to perform genetic testing as I attest that the patient has received and read the Claro Lab Informed Consent document, or has had it read to described. I also give permission for my specimen and clinical information to be used in de-identified studies at him or her, and that I have fully informed the patient about the purpose, capabilities, and limitations of the Claro Lab and for publication, if appropriate. My name or other personal identifying information will not be used ordered test. The patient has voluntarily given his or her full consent for the ordered test and a signed copy of in or linked to the results of any studies and publications. More information is available at this consent is available on file. Any Claro Lab Informed Consent that the patient agrees to at a later date will www.ClaroLaboratory.com/policies/privacy-policy. supersede and replace this Informed Consent. Opt out of research STATEMENT OF MEDICAL NECESSITY Check this box if you are a New York state resident and give permission for Claro Lab to retain any By signing below, I, the ordering Medical Provider, confirm that testing is medically necessary and that test results remaining sample longer than 60 days after the completion of testing. may impact medical management for the patient. PATIENT SIGNATURE (REQUIRED FOR BILLING PURPOSES) DATE (MM/DD/YYYY) ORDERING PROVIDER SIGNATURE (REQUIRED) DATE (MM/DD/YYYY) X X INSURANCE BILLING Attach front and back of all insurance cards, ABN, medical criteria form ICD-10 VALID CODE REFERRAL/PRIOR AUTH CLARO BENEFITS ID # By signing above, the patient or insured authorizes Claro Lab PLEASE ATTACH INSURANCE Genetics to release medical information concerning the test to the CARDS FOR BILLING assigned insurance company. PRIMARY INSURANCE ID INSURANCE NAME STATE GROUP INSURANCE PHONE # INSURANCE PLAN NAME OF INSURED RELATION TO PATIENT DATE OF BIRTH (MM/DD/YYYY) SECONDARY INSURANCE ID INSURANCE NAME STATE GROUP INSURANCE PHONE # INSURANCE PLAN NAME OF INSURED RELATION TO PATIENT DATE OF BIRTH (MM/DD/YYYY) INSTITUTIONAL BILLING SELF PAY By signing above, the patient or payor authorizes Claro Lab to INSTITUTION/PRACTICE NAME Use patient information above for billing contact them directly, and use the provided billing instructions Use information below for billing to bill the indicated method. ATTENTION TO PAYOR LAST NAME PAYOR FIRST NAME ADDRESS ADDRESS CITY STATE/PROVINCE POSTAL CODE COUNTRY CITY STATE/PROVINCE POSTAL CODE COUNTRY PHONE FAX/EMAIL PHONE FAX/EMAIL If I am covered by insurance, I authorize CLARO LABS and their contracted billing company to give my insurance carrier the information on this form and provided by my healthcare provider that is necessary for reimbursement. I understand that I am responsible for deductible and coinsurance amounts as indicated by my insurance carrier. I agree to assist in resolving insurance claim issue ans if I do not assist, I may be responsible for the sill cost of the test. I understand that I am responsible for sending CLARO LABS any and all of the money that I receive directly from my insurance carrier in payment for this test. If the test is not authorized by or is not covered by my insurance, than I will be contacted with the option to either cancel the ordered test or elect to pay out-of- pocket according to the proposed payment plan provided to me when I am contacted. If I elect to pay out-of-pocket, I will be responsible for all payment obligations arising from the ordered testing and guarantee payment for these services. I understand that if payments or arrangements are not made after 3 statements my information may be sent to collections. Claro Labs is committed to support you with your share of costs. If required, you will be contacted by our team to setup a payment plan for your portion of the costs using the following forms of payment: Check, Visa, Master Card. You may also contact our billing team at 518-702-4353 PATIENT SIGNATURE (REQUIRED FOR BILLING PURPOSES) DATE (MM/DD/YYYY) X CLARO LABS - A CLIA Accredited Laboratory: 408 Horizon Ave, Suite #101, Lafayette CO, 80026 P: (720) 287-3142 | F: (720) 863-2042 | [email protected] Page 1 of 2 Cardiovascular Test Requisition Please attach detailed medical records, insurance card front/back, and clinical information to the requisition form. CLINICAL HISTORY Attach any available detailed medical records and clinical notes Clinical Details Check all that apply: There are many factors which may affect genetic diagnostic testing: such as gene-gene interactions, high- risk ethnicity groups, and transplants. Please list any that may apply. For additional details, please see the Mosaicism Bone Marrow Transplant Known Chromosomal Gain/Loss Claro Lab website. Consanguinity Organ Transplant Known Gene Gain/Loss Please specify any that are checked above: Clinical Presentation Please indicate any clinical presentations and/or ndings that may be relevant to genetic testing: There are many presentations which may not seem like a direct association for disease. Please list the most suspected presentations and attach detailed medical records and/or pedigree. - Behavior - Phenotypes - Conditions - Physical - Pedigree/Family History - Symptoms Clinical Testing Please indicate any clinical testing results and/or ndings that may be relevant to genetic testing: Please also include tests that had a negative result. These tests help our clinical staff process the results of your testing. - Karyotype - Hearing - Imaging - Previous Genetic Testing - Growth Measurements - Pathology Reports - Vision - Biochemical Testing FAMILY HISTORY Attach pedigree and additional pages as needed FAMILY MEMBER 1 NAME RELATION TO PATIENT GENETIC SEX Male Female Unknown DIAGNOSIS AND/OR SYMPTOMS AGE OF ONSET DOB (MM/DD/YYYY) FAMILY MEMBER 2 NAME RELATION TO PATIENT GENETIC SEX Male Female Unknown DIAGNOSIS AND/OR SYMPTOMS AGE OF ONSET DOB (MM/DD/YYYY) FAMILY MEMBER 3 NAME RELATION TO PATIENT GENETIC SEX Male Female Unknown DIAGNOSIS AND/OR SYMPTOMS AGE OF ONSET DOB (MM/DD/YYYY) TEST REQUESTED - Select only ONE test Comprehensive Cardiomyopathy NGS Comprehensive Cardiovascular NGS Congenital Heart Disease Hypertrophic Cardiomyopathy NGS A2ML1, ABCC9, ACADVL, ACTA2, ACTB, ACTC1, ACTG1, ACTN2, A2ML1, ABCC9, ACADVL, ACTC1, ACTN2, ADA2, AGL, AKAP9, ACTC1, ACVR2B, AKT3, ALMS1, ARL6, ARMC4, B9D1, B9D2, A2ML1, ABCC9, ACADVL, ACTC1, ACTN2, AGL, ANKRD1, ACVR2B, ACVRL1, ADA2, AGL, AKAP9, ALMS1, ANK2, ANKRD1, ALMS1, ANK2, ANKRD1, BAG3, BRAF, CACNA1C, CACNB2, CALR3, BBS1, BBS10, BBS12, BBS2, BBS4, BBS5, BBS7, BBS9, BCOR, BAG3, BRAF, CACNA1C, CALR3, CAV3, CBL, CPT2, CRYAB, APOA5, APOB, B4GALT7, BAG3, BBS10, BCOR, BMPR2, BRAF, BRAF, CBL, CC2D2A, CCDC103, CCDC114, CCDC151, CCDC28B, CASQ2, CAV3, CAVIN4, CBL, CHRM2, CPT2, CRYAB, CSRP3, CTF1, CSRP3, CTF1, DES, DMD, DSC2, DSG2, DSP, DTNA, ELAC2, C1R, C1S, CACNA1C, CACNA2D1, CACNB2, CALM1, CALM2, CCDC39, CCDC40, CCDC65, CCNO, CEP290, CFAP298, CFAP53, CTNNA3, DES, DMD, DNAJC19, DOLK, DSC2, DSG2, DSP, DTNA, EMD, FHL1, FKTN, FLNC, FXN, GAA, GATA4, GATAD1, GLA, CALM3, CALR3, CASQ2, CAV1, CAV3, CAVIN4, CBL, CBS, CHD7, CITED2, CPS1, CRELD1, CYR61, DNAAF1, DNAAF2, ELAC2, EMD, EYA4, FHL1, FHL2, FKRP, FKTN, FLNC, FXN, GAA, HRAS, ILK, JPH2, JUP, KRAS, LAMA4, LAMP2, LDB3, LMNA, GATA4, GATA6, GATAD1, GLA, GPD1L, HCN4, HRAS, ILK, JPH2, CCDC103, CCDC39, CCDC40, CHD7, CHRM2, COL3A1, COL5A1, DNAAF3, DNAAF4, DNAAF5, DNAH11, DNAH5, DNAH8, DNAI1, MAP2K1, MAP2K2, MTO1, MYBPC3, MYH6, MYH7, MYL2, JUP, KCNE1, KCNE2, KCNE3, KCNH2, KCNJ2, KCNJ5, KCNJ8, COL5A2, COX15, CPT1A, CPT2, CRELD1, CRYAB, CSRP3, CTF1, DNAI2, DNAL1, DRC1, DTNA, ELN, FLNA, FOXF1, FOXH1, GATA4, MYL3, MYLK2, MYOM1, MYOZ2, MYPN, NEBL, NEXN, NF1, KCNQ1, KRAS, LAMA4, LAMP2, LDB3, LMNA, MAP2K1, MAP2K2, CTNNA3, DEPDC5, DES, DMD, DNAAF1, DNAAF2, DNAAF3, GATA6, GDF1, GJA1, GPC3, HAND1, HRAS, INVS, JAG1, KIF7, NRAS, PDLIM3, PKP2, PLN, PRKAG2, PTPN11, RAF1, RASA1, MIB1, MTO1, MYBPC3, MYH6, MYH7, MYL2, MYL3, MYLK2, DNAAF4, DNAAF5, DNAH11, DNAH5, DNAI1, DNAI2, DNAJC11, KRAS, LEFTY2, MAP2K1, MAP2K2, MCIDAS, MED13L, MKKS, RBM20, RIT1, RRAS, RYR2, SCN5A, SGCD, SHOC2, SOS1, MYOM1, MYOZ2, MYPN, NDUFB11, NEBL, NEXN, NF1, NKX2-5, DNAJC19, DNAL1, DOLK, DSC2, DSG2, DSP, DTNA, EFEMP2, MKS1, MMP21, MYH6, NEK8, NKX2-5, NKX2-6, NME8, NODAL, NPPA, NRAS, PDLIM3, PKP2, PLN, PRDM16, PRKAG2, PTPN11, ELAC2, ELN, EMD, ENG, EYA4, FBN1, FBN2, FGD1, FHL1, FHL2, NOTCH1, NPHP3, NR2F2, NRAS, NSD1, NTRK3, OFD1, PIK3CA, SOS2, SPRED1, TAZ, TCAP, TMEM43, TMPO, TNNC1, TNNI3, RAF1, RANGRF, RASA1, RBM20, RIT1, RRAS, RYR2, SCN1B, FKRP, FKTN, FLNA, FLNC, FOXH1, FXN, GAA, GATA4, GATA6, PIK3R2, PITX2, PKD1L1, PTPN11, RAF1, RAI1, RBM10, RIT1, TNNT2, TPM1, TTN, TTR, VCL ( 86 genes ) SCN3B,
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