Immunohistochemistry Requisition

Immunohistochemistry and Special Stain Requisition Phone 866.776.5907/ Fax 239.690.4237 neogenomics.com

Client Information Patient Information Required Information Account #: ______Account Name: ______Last Name: ______□ Male □ Female Street Address: ______First Name:______M.I.______Other Pt ID/Acct #: ______Date of Birth: mm______/ dd______/ yyyy______Medical Record #: ______City, ST, ZIP: ______Client represents it has obtained informed consent from patient to perform the services described herein. Phone: ______Fax: ______Specimen Information Requisition Completed by:______Date:______Ordering Physician (please print: Last, First):______NPI #:______Specimen ID:______Block ID:______Fixative/Preservative:______Treating Physician (please print: Last, First): ______NPI #:______The undersigned certifies that he/she is licensed to order the test(s) listed below and that such test(s) are medically necessary for Collection Date: mm______/ dd______/ yyyy______Collection Time:______□ AM □ PM the care/treatment of this patient. Retrieved Date: mm______/ dd______/ yyyy______Authorized Signature: ______Date: ______Hospital Discharge Date: mm______/ dd______/ yyyy______Billing Information Body Site:______Primary Metastasis – If Metastasis, list Primary:______Required: Please include face sheet and front/back of patient's insurance card. □ □ Patient Status (Must Choose 1): □ Hospital Patient (in) □ Hospital Patient (out) □ Non-Hospital Patient □ FNA cell block:______Bill to: □ Client Bill □ Insurance □ Medicare □ Medicaid □ Patient/Self-Pay □ Smears: Air Dried ______Fixed ______Stained (type of stain)______Split Billing - Client (TC) and Insurance (PC) OP Molecular to MCR, all other testing to Client □ □ □ Slides # ______Unstained ______Stained ______□ H&E______□ Bill charges to other Hospital/Facility: ______□ Paraffin Block(s) #: ______□ Choose best block (global testing only) P r i o r A u t h or i z a t i o n # ______See the NeoGenomics.com Billing section for more info. □ Perform tests on all blocks Clinical Information Breast Marker & Gastric/GEA HER2 Fixation (CAP/ASCO Requirement) Cold ischemic time ≤ 1 hour: Yes No Unknown Required: Please attach patient's pathology report (required), clinical history, and other applicable report(s). □ □ □ 10% neutral buffered formalin: □ Yes □ No □ Unknown ICD 10 (Diagnosis) Code/Narrative (Required):______HER2/ER/PgR Fixation duration 6 to 72 hours: □ Yes □ No □ Unknown Reason for Referral: ______□ New Diagnosis □ Relapse □ In Remission □ Monitoring G - Global G-IA - Global with Image Analysis T - Tech-Only/Stain-Only T-IA - Tech-Only with Image Analysis Staging: □ 0 □ I □ II □ III □ IV Note: ______T-SQnt - Tech-Only with Semi-Quantitative interpretation by client Consultation - A NeoGenomics pathologist will select medically necessary tests with Tech-Only Qualitative IHC/ISH/Special Stains Bold indicates global prognostic interpretation is available. any exception noted below by the client to provide comprehensive analysis and professional Check here to add interpretation for the materials submitted. Performed on FFPE only. □ □ Surgical Pathology Consult (FFPE only) □ Add NeoTYPE® Profile if indicated □ AAT □CD15 □D240 □LMO2 □PD1 Special Stains Differential Diagnosis: ______ □ACTH □CD19 □DBA.44 □Lysozyme □PD1 (non-heme) G T □AFP □CD20 □Desmin □MAL □Perforin N/A □ Alcian Blue Image Analysis/Semi-Quantitative IHC □Albumin RNA ISH □CD21 □DOG1 □Mammaglobin □PgR □ □ Calcium Stain G-IA T-IA T-SQnt G-IA T-IA T-SQnt □ALK-1 (Heme) □CD22 □DPC4 □MDM2 □PIT1 N/A □ Colloidal Iron □ □ □ AR □ □ □ MLH1 □Annexin A1 □CD23 □EBV (LMP1) □Melan A (Mart1) □PLAP N/A □ Congo Red □ □ □ ER □ □ □ MSH2 □AR □CD25 □E-Cadherin □Melan A/Ki67 □PRAME N/A □ Copper Stain □ □ □ HER2 Breast** □ □ □ MSH6 □Arginase 1 □CD30 □EMA □Melanoma Micromets □Prolactin N/A □ Elastic Stain □ □ □ Ki67 □ □ □ PMS2 □ATRX □CD31 □ER (HMB45 with Melan A/ □Prostate Triple Stain N/A □ Fontana Masson □ □ □ PgR □B72.3 □CD33 □ERG Mart1) □PSA N/A □ Giemsa □ □ □ p53 □BAP1 □CD34 □Factor VIII RA □Mesothelin □PSAP/HPAP N/A □ Iron **For global HER2 IHC with result 2+, NeoGenomics □BCA-225 □CD35 □Factor XIIIa Mismatch Repair (MMR) □PSMA □ □ MPO Cytochemical will add global HER2 FISH unless marked here: □ Do not reflex 2+ □BCL1/Cyclin D1 □CD38 □Fascin □ MLH1 □PTH N/A □ Mucicarmine Semi-Quantitative □BCL1/Cyclin D1 □CD42b □Fli-1 □MSH2 □RCC1 N/A PAS MSH6 □ G T G T G T (non-heme) □CD43 □FOXP1 □ □S100 N/A □ PASD □BCL2 □CD44 □FOXP3 □PMS2 □S100p Periodic Acid Schiff □□ BRCA1 □□ Ki67 NET □□ PD-L1 SP263 FDA All 4 Stains □ □ □□ cMET □□ p21 (IMFINZI®)* □BCL2 □CD45 (LCA) □FSH □ □SALL4 with Digestion □□ COX2 □□ p27 □□ pHistone H3 (PHH3) (non-heme) □CD45RO □Galectin 3 □MITF □SATB2 (PASD+PAS) EGFR pAKT PTEN □BCL2 (SP66) □CD56 □GATA3 □MOC31 □Serotonin N/A □ Reticulin □□ □□ □□ MPO N/A ERCC1 PD-L1 22C3 FDA (KEYTRUDA®) Retinoblastoma □BCL6 □CD57 □GATA3 (heme) □ □SF1 □ Trichrome □□ *□□ MSA N/A HER2 Colorectal^ Cervical Protein (RB) □BCL10 □CD61 □GCDFP15 □ □SMA □ Wright Giemsa □□ □□ MUC1 □□ HER2 Gastric/GEA** □□ ESCC (Esophageal) □□ RRM1 □BerEP4 □CD68 □GCET1 □ □SMMHC □□ HER2 (Other)** □□ Gastric/GEA □□ TOPO1 □Beta Catenin □CD68 (PG-M1) □GFAP □MUC2 □Smoothelin In-Situ Hybridization □ Breast Scoring (Default) □□ HNSCC (Head & Neck) □□ Thymidylate □BG8 □CD71 □GH □MUC4 □Somatostatin (Tech-Only) or NSCLC Synthase □BOB1 CD79a Glucagon □MUC5 SSTR2 □□ □ □ □ □EBER ISH □ Gastric Scoring □□ TNBC (Breast) □□ VEGF □BRAF V600E □CD99 □Glutamine □MUC6 (Somatostatin □□ Urothelial Carcinoma □Breast □CD103 Synthetase □MUM1 Receptor, Type 2) □Kappa/Lambda ISH PD-L1 SP142 FDA (TECENTRIQ®) Triple Stain CD117 cKIT GLUT1 MyoD1 SOX2 ^ For global HER2 IHC w/results 3+ * □ □ □ □ □ Other in 11-49% and/or 2+ is 50% cells, NSCLC (CK5+p63+CK CD117 cKIT □Glycophorin A □Myogenin □SOX10 ≥ □□ □ (Specify):______NeoGenomics will add global HER2 FISH, □□ TNBC (Breast) 8/18) (Melanoma) □Glypican-3 □Myoglobin □SOX11 □ unless Tech reflex option(s) are marked or □□ Urothelial Carcinoma □BRG1 □CD123 □Granzyme B □Napsin A □STAT6 “Do Not Reflex” is marked here: □□ PD-L1 28-8 FDA (OPDIVO®)* (SMARCA4) □CD138 □H3K27me3 □NeuN □Surfactant ______□Do Not Reflex □□ PD-L1 28-8 FDA (OPDIVO® + YERVOY® for NSCLC)* □CA19.9 □CD163 □HBME1 □NF (Neurofilament) □Synaptophysin *Ordering Pathologist listed has received the required competency training to □CA125 □CDK4 □HCG Beta □NGFR □TCL1 Qualitative perform the professional interpretation for this test. Calcitonin CDX2 Hemoglobin A NKX2.2 TCR BetaF1 G T □ □ □ □ □ G T G T □Caldesmon □CDX2/CK7 □HepPar1 □NKX3.1 □TCR Delta ALK, D5F3 BRAF V600E □□ □ Gastrin NSE □□ □ □□ □ N/A □Calponin Double Stain □HGAL □ □TdT (lung, FDA) (non-heme) □ Pan-TRK Calretinin NUT p16 □ □CEA (Mono) □HMB45 □ □TFE3 N/A □ Amyloid A □□ □ EGFR (L858R mutant □□ □ □CAM 5.2 □CEA (Poly) □HPL □OCT2 □Thrombomodulin (TM) N/A Amyloid P specific) □ □ ROS1 OCT4 □ ZAP70 □Carbonic □Chromogranin A □ICOS □ □Thyroglobulin (TGB) □ N/A Amyloid A&P Panel □□ □ EGFR (E746-A750 □□ □ Anhydrase IX □CK 5/6 □ICOS (non-heme) □Olig2 □TIA1 (global only)* del specific) (CA IX) □CK 7 □IDH1 □p40 □TLE1 *Congo Red slide must accompany sample OR order Consult □Carcinoma □CK 14 □IgA □p53 □TRAcP Infectious Disease Micromets □CK 17 □IgD □p57 □Tryptase G T G T G T (levels with □CK 18 □IgG □p63 □TSH □□ □ Adenovirus □□ □ Hep B Surface □□ □ Parvovirus AE1/AE3) □CK 19 □IgG4 □p63 (heme) □TTF1 □ □ AFB Antigen □ □ Periodic Acid □CD1a □CK 20 □IgM □p120 Catenin □Tyrosinase □□ □ CMV (IHC) □□ □ HHV8 Schiff for Fungus (PASF) □CD2 □CK HMW □Inhibin □p501S □Uroplakin II □ □ CMV (ISH) □ N/A HPV RNA ISH □□ □ Pneumocystis □CD3 (CK903/34βBE12) □INI1 □p504S □Uroplakin III □□ □ EBER ISH (head & neck) Panel (Complete) Carinii (Jiroveci) □CD4 □CK HMW/LMW □INSM1 □Pan-Cytokeratin □Villin N/A □ EBER ISH (heme) □ N/A HPV RNA ISH □□ □ Spirochete CD5 Double Stain Insulin Pan-Cytokeratin N/A □ □ □ □Vimentin □ EBV (LMP1) 16/18 High Risk □ □ SV40 □CD7 □CK OSCAR □Kappa/Lambda IHC (sentinel-node) □WT1 □□ □ Fite □ N/A HPV RNA ISH □□ □ Toxoplasma □CD8 □cMyc □Ki67 □Parafibromin □□ □ GMS High Risk Cocktail □ □ Tuberculosis □CD10 □Collagen IV □Langerin □PAX2 Gram Stain □ N/A HPV RNA ISH □□ □ Varicella Zoster CD11c cREL LEF1 PAX5 □ □ Virus (VZV) □ □ □ □ □□ □ H. Pylori Low Risk Cocktail □CD14 □CXCL13 □LH □PAX8 □ □ Hep B Core Antigen □□ □ HSV I/II □□ □ Warthin Starry For our complete test menu, TAT, specimen requirements and more, please visit neogenomics.com Rev. 010621 Specimen Requirements Refrigerate specimen if not shipping immediately and use cool pack during transport. Please call Client Services Team with any questions regarding specimen requirements or shipping instructions at 866.776.5907 option 1. Please refer to the website for specific details on each specimen.

Additional Billing Information Any organization referring specimens for testing services pursuant to this Requisition Form (“Client”) expressly agrees to the following terms and conditions. 1. Binding Service Order. This Requisition Form is a legally binding order for the services ordered hereunder (“Services”) and Client agrees that it is financially responsible for all tests billable to Client hereunder. 2. Third Party Billing by NeoGenomics and Right to Bill Client. Client agrees to accurately indicate on the front of the Requisition Form that either Client should be billed (e.g., Client receives reimbursement pursuant to a non-fee-for-service basis, including, but not limited to, a capitated, diagnostic related group (“DRG”), per diem, all-inclusive, or other such bundled or consolidated billing arrangement) or NeoGenomics should bill the applicable federal, state or commercial health insurer or other third party payer (collectively, “Payers”) for all Services ordered pursuant to this Requisition Form. For all such Services billable to Payers, Client agrees to provide all billing information necessary for NeoGenomics to bill such payer. In the event NeoGenomics: (i) does not receive the billing information required for it to bill any Payers within ten days of the date that any Services are reported by NeoGenomics; (ii) the Services were performed for patients who have no Payer coverage arrangements; or (iii) the Payer identified by Client denies financial responsibility for the Services and indicates that Client is financially responsible, NeoGenomics shall have the right to bill such Services to Client.

Test Descriptions Please see complete test descriptions and all available tests at our website, www.neogenomics.com. Test Notations Specimen Usage NeoGenomics makes every effort to preserve and not exhaust tissue, but in small and thin specimens, there is a possibility of exhausting the specimen in order to ensure adequate material and reliable results.