PYRUVATE METABOLISM AND RELATED DISORDERS REQUISITON FORM CENTER FOR INHERITED DISORDERS OF ENERGY METABOLISM (CIDEM) University Hospitals Case Medical Center 11100 Euclid Ave., Wearn Bldg. Rm. 649 Cleveland, OH 44106 Phone: (216) 844-1286 • Fax: (216) 844-8005 www.cwru.edu/med/CIDEM/cidem.htm Patient Information Name (Last, First, Middle) Diagnosis is REQUIRED before sample can be tested: (check all that apply) Clinical Summary attached 

Date of Birth Sex  277.87 Mitochondrial disorder  276.2 Lactic acidosis  277.9 Metabolic disorder  781.3 Hypotonia  359.9 Myopathy,unspecified  780.39 Seizures Medical Record Number  783.40 Developmental delay  783.41 Failure to thrive Other: (ICD-9 codes)______Referring Physician Information Referring Lab Information/Billing Address Name (To whom the original report will be mailed) NPI# Name

.

Signature Lab/Building

Hospital Hospital

Street City State Zip Street City State Zip

Phone Fax (Results will NOT be faxed to this number) Phone Fax(es) (To which results will be sent)

Invoices will be directed to the Referring Lab, unless complete information is provided to bill the patient’s private insurance company or Ohio Medicaid. We cannot accept government programs other than Ohio Medicaid. Sample Information (Only one sample type per requisition) COLLECTION DATE (REQUIRED) COLLECTION TIME SENDER ACCESSION NO.

AM PM

* ADVANCE SCHEDULING REQUIRED FOR: Sample Types: H - Heart B - ACD Blood for Lymphocytes L – Liver B - ACD Blood for Lymphocytes E - EDTA Blood for DNA isolation M - Skeletal Muscle F - Skin Fibroblasts (Mycoplasma Testing REQUIRED) F - Skin Fibroblasts Mycoplasma testing at CIDEM

Combined Functional plus Molecular Testing Option on Blood Check box Turnaround Time (see CPT codes and Price List for details) Requires ACD and EDTA blood tubes (B* & E types) 6 wks for NGS Complex (PDC) Assay + 23- NGS Panel <1 wk for PDC assay 23-Gene NGS Pyruvate Metabolism Panel: Analysis of PDHA1, PDHB, PDHX, DLAT, DLD, BOLA3, LIAS, LIPT1, LIPT2, NFU1, PC, PCK1, PCK2, PDK1, PDK2, PDK3, PDK4, PDP1, PDP2, SLC19A2, SLC19A3, SLC25A19 and TPK1 by Next Generation Sequencing (NGS). Check the appropriate Single Testing Options (see CPT codes and Price List for details) box(es) Comment B* E F* H L M Functional Pyruvate Dehydrogenase Complex (PDC) -Ketoglutarate Dehydrogenase Complex (KDC) Pyruvate Carboxylase (PC) Phosphoenolpyruvate Carboxykinase (PEPCK) Molecular 23-Gene NGS Pyruvate Metabolism Panel PDHA1(Sanger sequencing) PDHB (Sanger sequencing) DLAT (Sanger sequencing) DLD (Sanger sequencing) PDHX (Sanger sequencing) PC (Sanger sequencing) CIDEM or CHGL USE ONLY

Date Received: ______CIDEM #: ______GENETIC ID#: ______Sample Amt: ______