Prorenata Laboratories, LLC Toll Free: 1-888-680-0014 • Fax: 1-833-297-0961 8222 S. 48th Street, Suite 210 • Phoenix, Arizona 85044 Director: Joshua Bornhorst, Ph.D., DABCC, FACB CLIA# 03D2147626 PATIENT INFORMATION

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Printed Physician Name

Patient/Guardian Signature Date Physician Signature Date Patient/Guardian Signature Date Physician Signature Date ICD-10 CODES ANTIBIOTIC RESISTANCE  Carcinoma in situ of (D06.9) or  N82.1 Other female urinary-genital tract  R39.89 Other and unspecified symptoms  Z16.30 Resistance to unspecified (D07.1) or (D07.2) fistulae and signs involving the urinary antimicrobialPatient/Guardian drugs Signature  D07.30 CarcinomaDate in situ of unspecified  N82.4 Other female Physicianintestinal-genital Signature tract system Date  Z16.31 Resistance to antiparasitic drug(s) female genital organs ( ) D07.39 fistulae  R39.9 Unspecified symptoms and signs  Z16.32 Resistance to antifungal drug(s) Carcinoma in situ of other female  N86 Erosion, ectropion of cervix uteri involving the GU system  Z16.33 Resistance to antiviral drug(s) genital organs  N87.9 Dysplasia of cervix uteri  R50.9 Fever, unspecified  Z16.35 Resistance to multiple antimicrobial  D07.60 Carcinoma in situ of unspecified  N88.0 of cervix uteri  R80.0 Isolated proteinuria drugs male genital organs ( ) D07.61  N89.3 Dysplasia of vagina  R82.3 Hemoglobinuria  Z16.39 Resistance to other specified Carcinoma in situ of scrotum  N90.3 Dysplasia of vulva  R82.90 Other unspecified abnormal antimicrobial drugs  D07.69 Carcinoma in situ of other male  N90.4 Leukoplakia of vulva findings in urine (positive nitrite or  Z16.341 Resistance to single genital organs  N41.0 Acute prostatitis leukocyte esterase) antimycobacterial drug  N30.00 Acute cystitis without hematuria  N41.1 Chronic prostatitis  R87.614 Cytologic evidence malignancy,  Z16.342 Resistance to multiple  N30.10 Interstitial cystitis (chronic) without  N41.9 Inflammatory disease of prostate, cervix or vagina (R87.624) antimycobacterial drugs hematuria unspecified  R87.610 Atypical squamous cells of  N30.40 Irradiation cystitis without  N34.1 Nonspecific urethritis undetermined significance (ASC- GENITO-URINARY hematuria  N34.3 Urethral syndrome, NOS US), cytologic smear of cervix () or  A60.00 HSV of urogenital system,  N30.90 Cystitis, NOS without hematuria  N39.0 Urinary tract infection, site not vagina (R87.620)( ) ASC-US, can’t unspecified  N70.93 and , NOS specified exclude high grade squamous  A60.1 HSV infection, perianal skin/rectum  N71.9 Inflammatory disease of ,  N49.9 Inflammatory disorder of intraepithelial lesion (ASC-H), cervix  A60.9 Anogenital herpes viral infection, NOS unspecified male genital organ (R87.611) or vagina (R87.621) unspecified  N73.9 Female pelvic inflammatory  R10.2 Pelvic/perineal pain  R87.612 Low grade squamous intraepithelial  A63.0 Anogenital (venereal) warts disease, NOS  R30.0 Dysuria lesion (LGSIL), cytologic smear of  A64 Unspecified sexually transmitted  N72 Inflammatory disease of cervix  R30.9 Painful micturiton, unspecified cervix or vagina (R87.622) disease uteri (with or without ulcer or  R31.9 Hematuria, unspecified  R87.613 High grade squamous  B00.9 Herpes viral infection, unspecified erosion)  R35.8 Polyuria, NOS intraepithelial lesion (HGSIL),  B37.3 Candidiasis, vulva/vagina  N76.0 Acute  R36.9 Urethral discharge, unspecified cytologic smear of cervix or vagina  B37.49 Candidiasis, other urogenital  N76.1 Subacute/chronic vaginitis  R35.0 Frequency of micturiton (R87.623)  B37.9 Candidiasis, unspecified  Ulceration of vagina (N76.5) or vulva (N76.6)  R39.15 Urgency of Urination  R87.810 Cervical high risk human  C53.9 Malignant neoplasm of cervix uteri,  N82.0 Vesicovaginal  R39.198 Other difficulties with micturition papillomavirus (HPV) DNA test positive unspecified  N82.9 Female genital tract fistula, NOS  R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive URINARY TRACT INFECTION BACTERIA  Providencia Stuartii  streptoccoccus agalactia (group B)  tet B, tet M  Escherichia coli  Staphylococcus aureus* gardnerella vaginalis  ermB, C; mefA  Pseudomonas aeruginosa  Staphylococcus (coagulase negative: FUNGAL  dfr (A1, A5), sul (1,2) probes  Enetrococcus faecium, faecalis epidermidis, haemolyticus, lugdunensis,  Candida albicans, glabrata, parapsilosis, (Sulfamethoxazole and trimethoprim)  Enterobacter aerogenes, cloacae saprophyticus) tropicalis  IMP, NDM, VIM Groups (Carbapenem)  Klebsiella pneumoniae/ oxytoca  Staphylococcus saprophyticus STI  ACT, MIR, FOX, ACC Groups (Beta Lactams)  Acinobacter baumannii  Streptococcus, Group A [pyogenes]  trichomonas vaginalis  PER-1/VEB-1/GES-1 Groups (ESBL)  Proteus mirabilis, vulgaris  Viridians Group Streptococcus (anginosus,  neisseria gonorrhoeae  VanA, VanB (Vancomycin)  oralis, pasteuranus)  chlamydia trachomatis  Sul I Sul II  Serratia marcescens  Haemophilus influenzae  Mycoplasma genitalium, hominis  MRSA* Mec-A gene  Citrobacter koseri  Corynebacterium urealyticum ANTIBIOTIC RESISTANCE  Class A β-lactamase; blaKPC  Citrobacter freundii/braakii  Mobiluncus curtissi, mobilunucs mulieris  Class D oxacillinase OXA-48  Class A β-lactamase; CTX-M-Group1  Morganella Morganii  Ureaplasma urealyticum, parvum  Class D oxacillinase OXA--51  Class B metallo-β-lactamase; blaNDM  Bacteroides fragilis  qnrA1, A2, B2  qnrB & qnrS INSURANCE INFORMATION & REQUIRED ATTACHMENTS Urinary Tract Pathogens Specimen Collection Instructions DĂƚĞƌŝĂůƐWƌŽǀŝĚĞĚ ůŝŶŝĐĂůdĞĐŚŶŝĐŝĂŶ/ŶƐƚƌƵĐƟŽŶƐ EŽŶͲůĞĂŶͲĂƚĐŚWƌŽĐĞĚƵƌĞ ϭ͘WƵƚŽŶƐƚĞƌŝůĞŐůŽǀĞƐ͘ hƐŝŶŐĂƐƚĞƌŝůĞƉůĂƐƟĐƚƌĂŶƐĨĞƌƉŝƉĞƩĞ;ŶŽƚƉƌŽǀŝĚĞĚͿ ĮƌƐƚŵŽƌŶŝŶŐƐĂŵƉůĞŽƌƐĂŵƉůĞĐŽůůĞĐƚĞĚůŽŶŐĞƌƚŚĂŶϭͲϮ ŚŽƵƌƐƐŝŶĐĞƉƌŝŽƌƵƌŝŶĂƟŽŶŵĂdžŝŵŝnjĞƐƐĞŶƐŝƟǀŝƚLJŽĨĚĞƚĞĐƟŶŐ Ă͘^ǁŝƌůƚŚĞƉŝƉĞƩĞϭϬͲϭϱƟŵĞƐƚŽŵŝdžƚŚĞƐĂŵƉůĞ͘ ƵƌŝŶĂƌLJƐLJƐƚĞŵƉĂƚŚŽŐĞŶƐ͘ ď͘dƌĂŶƐĨĞƌĂƚůĞĂƐƚϮŵ>ŽĨƵƌŝŶĞĨƌŽŵƚŚĞĐŽůůĞĐƟŽŶĐƵƉ ƚŽƚŚĞŵŽůĞĐƵůĂƌƚƌĂŶƐƉŽƌƚƚƵďĞ͘ WĂƟĞŶƚ/ŶƐƚƌƵĐƟŽŶƐ Đ͘^ĞĐƵƌĞůLJƟŐŚƚĞŶƚŚĞĐĂƉŽĨƚŚĞƚƌĂŶƐƉŽƌƚƚƵďĞ͘ ϭ͘ tĂƐŚŚĂŶĚƐƚŚŽƌŽƵŐŚůLJǁŝƚŚǁĂƌŵǁĂƚĞƌĂŶĚƐŽĂƉ͘ ϯ͘WůĂĐĞĂůĂďĞůǁŝƚŚƚǁŽƉĂƟĞŶƚŝĚĞŶƟĮĞƌƐŽŶƚŚĞƚƵďĞ͘ &ĞŵĂůĞƐ͗ ,ŽůĚŝŶŐůĂďŝĂĂƉĂƌƚ͕ĐŽůůĞĐƚĮƌƐƚΕϭϬͲϮϱŵ>ƵƌŝŶĞŝŶƚŽ ϰ͘<ĞĞƉƚŚĞƚƵďĞŝŶƚŚĞƵƉƌŝŐŚƚƉŽƐŝƟŽŶĨŽƌϭϬʹϭϱŵŝŶƵƚĞƐ ƉƌŽǀŝĚĞĚƐƚĞƌŝůĞƵƌŝŶĞĐƵƉ͘ ďĞĨŽƌĞƉůĂĐŝŶŐŝƚŝŶƚŚĞƉƌŽǀŝĚĞĚƐƉĞĐŝŵĞŶďĂŐ͘ DĂůĞƐ͗ ϱ͘WůĂĐĞĂůůƐĂŵƉůĞƐĐŽůůĞĐƚĞĚĨŽƌƚŚĞĚĂLJŝŶƚŽĂƉƌŽǀŝĚĞĚhW^ͬ  ZĞƚƌĂĐƚĨŽƌĞƐŬŝŶ;ĂƐĂƉƉůŝĐĂďůĞͿ͕ĐŽůůĞĐƚĮƌƐƚΕϭϬͲϮϱŵ> &ĞĚdž>ĂďWĂŬŵĂŝůĞƌ͘^ĞĂůƚŚĞŵĂŝůĞƌĂŶĚƉůĂĐĞĂƐŚŝƉƉŝŶŐůĂďĞů ƵƌŝŶĞŝŶƚŽƉƌŽǀŝĚĞĚƐƚĞƌŝůĞƵƌŝŶĞĐƵƉ͘ Ϯ͘ ^ĞĐƵƌĞůLJƉůĂĐĞĐĂƉŽŶƵƌŝŶĞĐƵƉ͕ĂŶĚŐŝǀĞƚŽƚŚĞĐůŝŶŝĐĂů ƚĞĐŚŶŝĐŝĂŶ͘ 6SJOBSZ5SBDU*OGFDUJPO           /DEHO7XEHV,PPHGLDWHO\ v Must use SURYLGHGODEODEHO)LOORXWSHHOVWLFNWRWXEH v /DEHOWXEHLQ sight of patient v 3XWSDWLHQWVIXOOQDPHDQGGDWHRIELUWK v 'DWHRIFROOHFWLRQ WLPH ^W/DE^,/WDEd͗ ϭ͘ hW^^ŚŝƉŵĞŶƚƐ͗ĨƚĞƌĨŽůůŽǁŝŶŐƚŚĞƚƌĂŶƐĨĞƌͬůĂďĞůŝŶŐƐƚĞƉƐĂďŽǀĞ͕ƉůĂĐĞƚŚĞƐĂŵƉůĞƐ ŝŶƐŝĚĞƚŚĞƐƉĞĐŝŵĞŶďŝŽŚĂnjĂƌĚŽƵƐďĂŐĂŶĚĂƉƉůLJƚŚĞnjŝƉͲůŽĐŬƐĞĂů͘

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