2119 E. 93rd / L15 Cleveland, OH 44106 IMMUNOHISTOCHEMISTRY (IHC), 216.444.5755 or 800.628.6816 SPECIAL STAINS (SS), & CISH REQUISITION <
PATIENT INFORMATION (PLEASE PRINT IN BLACK INK) CLIENT INFORMATION ______Last Name First MI ______Address Birth Date Sex ¨ M ¨ F ______City SS # ______State Zip Home Phone ______Hospital/Physician Office atientP ID # Accession # ORDERING PHYSICIAN CONTACT
MEDICAL NECESSITY NOTICE: When ordering tests for which Medicare reimbursement will be sought, physicians (or other individuals authorized by law to order tests) should only order tests that are medically necessary for the diagnosis or treatment of a patient, rather than for screening purposes. ______Physician Name INSURANCE BILLING INFORMATION (PLEASE ATTACH CARD OR PRINT IN BLACK INK)
BILL TO: ¨ Client/Institution ¨ Medicare ¨ Insurance (Complete insurance information below) ¨ Patient ______PATIENT STATUS: ¨ Inpatient ¨ Outpatient ¨ Non-Hospital Patient Hospital discharge date: ______/______/______Physician NPI# PRIMARY: ¨ Medicare ¨ Medicaid ¨ Other Ins. ______¨ Self ¨ Spouse ¨ Child ______Physician Phone Subscriber Last Name First MI ______Physician Email Beneficiary / Member # Group #
______Claims Address City State Zip ¨ Call Results to phone number: (______) ______
SECONDARY: ¨ No ¨ Yes (if Yes, please attach) ¨ Fax report to: (______) ______DIAGNOSIS CODE (REQUIRED) ICD-10 Codes 1. ______2. ______3. ______
SPECIMEN INFORMATION Other: ______¨ *Paraffin Blocks/Preferred Specimen type Collection Date: _____ / _____ / _____ Time: ______Tissue Block ID#(s):______Breast Samples: CAP / ASCO Requirements Cell Block ID#(s): ______10% neutral buffered formalin: ¨ Yes ¨ No ¨ Unknown Retrieved from Archive Date: _____ / _____ / _____ ¨ Slides (positive charged) HER2 Fixation >6 and <48 hours: ¨ Yes ¨ No ¨ Unknown Unstained Slide ID#(s):______ER/PR Fixation >6 and <48 hours: ¨ Yes ¨ No ¨ Unknown Body Site: ______Cold ischemic time ≤ 1 hour: ¨ Yes ¨ No ¨ Unknown
TECHNICAL-ONLY TESTING SERVICES Cleveland Clinic Laboratories offers eIHC and eSS products to provide expedited services to pathologists who have ordered IHC and Special Stains Technical-Only services. Whole slide images of the glass slides can be made available online within 24 hours of the material receipt via our secure online respository at https://slidedepot.clevelandclinic.org. • Clients can follow a staining algorithm rather than initially requesting a large number of stains, some of which may ultimately be unnecessary. Additional stains can be ordered without re-submitting the paraffin block: 1. Clients submit paraffin block(s) for testing 2. Cleveland Clinic can create an additional five unstained slides which allows for up to five additional stains to be performed as long as two months after the initial request 3. Simply fill out a new requisition and fax it to 216.445.0724 4. Additional stains may be received the same day • Cases contain specimens and slide information, as well as controls that are conveniently at your fingertips. An email notification is sent when scanned slide images are available for viewing.
¨ eIHC/eSS – Check here to receive rapid access to whole slide images of IHC/Special stains* Email address: ______*Email required to access images ¨ Check here if this case had eIHC/eSS performed at Cleveland Clinic within the last two months (Block shipment may not be required). Please contact ePathology Services at [email protected] to confirm. ______
¨ Technical Stain Only – Check here to have slides/blocks returned by UPS/FedEx ______
GLOBAL TESTING SERVICES ¨ Stain with Cleveland Clinic Pathologist Interpretation ______
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Antibody Clone Antibody Clone Antibody Clone GROUP I (Microorganisms) 14-3-3 Sigma 1433S01 Cytokeratin 7 OV-TL 12/30 Myogenin F5D Fite ACTH polyclonal Cytokeratin 19 A53-B/A2.26 NapsinA EP205 Gomori's Methenamine Silver (GMS) Actin, Muscle Specific HHF35 Cytokeratin 20 Ks20.8 Neurofilament 2F11 Gram Actin Smooth Muscle 1A4 Cytokeratin AE1/AE3 AE1/AE3 Neurofilament Cocktail 2F11+SMI32 Gridley Adenovirus M58+M73 Cytokeratin CAM 5.2 CAM 5.2 NK1/C3 NK1/C3 Steiner AFP polyclonal Cytokeratin KER903 34BE12 NKX3.1 polyclonal PAS/light green counterstain ALK D5F3 D2-40 D2-40 OCT-2 polyclonal Warthin-Starry ALK--1 ALK-1 Desmin D33 OCT 3/4 C10 Ziehl-Neelsen AFB AMACR (p504s) 13H4 DOG-1 K9 p16 E6H4 Amyloid A mc1 EBNA-2 PE2 p40 BC28 Amyloid Kappa polyclonal EBV CS1, CS2, CS3, CS4 p53 DO-7 GROUP II (All Other) Amyloid Lambda polyclonal E-Cadherin 4A2C7 p57 Ab-6 Alcian Blue, pH 2.5 Androgen Receptor AR441 EGFR 3C6 p63 4A4 Alcian Blue/Hyaluronidase Annexin A1 MRQ-3 EMA E29 p63/ERG DS 4A4+EPR3864 Alcian Blue/PAS Arginase-1 SP156 Enolase (NSE) BBS/NC/VI-H14 p501s 10E3 Aldehyde Fuchsin B72.3 (TAG-72) B72.3 EP4-Ber BER-EP4 PAP polyclonal Alizarin Red S b-Catenin 14 ER SP1 PAX-2 EP3251 ASD "Leder's Modificationi" BCL2 124 ERG EPR3864 PAX-5 24 Bielschowsky BCL2 EP36 EP36 FACTOR VIII polyclonal PAX-8 polyclonal Bile, Hall's Method BCL-6 PG-B6p FACTOR XIIIa AC-1A1 P-Component polyclonal Bodian BOB-1 polyclonal Fascin 55K-2 Perforin 5B10 Colloidal Iron C3d polyclonal FGFR3 B-9 PD1 NAT Colloidal Iron/Hyaluronidase C4d polyclonal FOXP1 C-19 PDGFR C20 Congo Red CA 125 M11 FOX-P3 236A/E7 PIN cocktail (p63/AMACR) 4A4+13H4 Copper (Rhodanine) CA IX polyclonal FSH polyclonal PLAP 8A9 Crystal Violet Calcitonin polyclonal Galectin PC4 PMS2 A16-4 Elastic (EVG) Calponin CALP Gastrin polyclonal PR 1.00E+02 Fontana-Masson Calretinin polyclonal GATA-3 L50-823 Prolactin polyclonal Giemsa (Mast Cell) CD1a O10 GCDFP-24 D6 PSA polyclonal Grimelius CD2 AB75 GCET1 RAM341 PSMA 3.00E+06 Iron Stain CD3 2VG6 GFAP polyclonal PTEN 6H2.1 Jones Methenamine Silver CD4 1F6 GH polyclonal PTH 105G7 Loxol Fast Blue CD5 4C7 Glucagon polyclonal RCC PN-15 Masson Trichrome CD7 LP15 Glutamine Synthetase GS-6 S-100 polyclonal Melanin Bleach CD8 1A5 Glypican-3 1G12 SALL4 6E3 Movat CD10 56C6 Granzyme B GrB-7 Serotonin polyclonal CD15 BRA4F1 HBcAg polyclonal SF-1 N1665 Mucicarmine CD19 BT51E HBsAg S1-210 SMMS1 SMMS1 Oil Red O CD20 L26 H-Caldesmon h-CD SOX10 polyclonal Orcein CD21 1F8 HCG polyclonal SOX-11 MRQ-58 PAS/amylase (PAS/D) CD22 FPC1 HER2 Neu 4B5 pSTAT 5 Y694/a Periodic Acid-Schiff (PAS) CD23 BU38 Hepatocyte OCH1ES STAT6 YE361 PTAH CD25 4C9 Herpes (HSVI&II) polyclonal Synaptophysin snp88 Reticulum CD30 BER-H2 HHV8 13B10 Syphilis polyclonal SAB CD31 JC/70A HMB-45 HMB-45 Tau/B-amyloid DS poly+6F/3D Tioflavin S CD33 PWS44 HPV KIH8 TCL-1A 1-21 Toluidine Blue CD34 QBEnd/10 IDH-1 H09 TCR BF1 8A3 Uric Acid CD35 Ber-MAC-DCR IgA polyclonal TCR-Gamma γ3.20 Von Kossa CD43 DF-T1 IgD polyclonal TdT polyclonal CD44 DF1485 IgG polyclonal TFE-3 MRQ-47 HISTOCHEMICAL STAINS (Enzyme) CD45 2B11,PD7/26 IgG4 HP6025 Thyroglobulin polyclonal CD45RO A6 IgM polyclonal TIA TIA-1 Acetylcholinesterase (ACE) CD56 1B6 Inhibin R1 Transthyretin 1F5 Acid Phosphatase CD57 NK-1 INI-1 25/BAF47 Tryptase, Mast Cell polyclonal Alkaline Phosphatase CD61 2F2 Insulin polyclonal TSH polyclonal ATP (4.6, 9.8) CD68 KP-1 Kappa polyclonal TTF-1 8G7G3/1 Cytochrome C CD68 PG-M1 Ki 67 30-9 Tyrosinase T311 Esterase CD71 10F11 Lambda polyclonal Ubiqutin polyclonal NADH CD79a JCB117 Langerin 12D6 Vimentin 3B4 Phosphofructokinase CD99 H036-1.1 LEF1 EPR2029Y VS38C VS38c Phosphorylase CD117 polyclonal LH C93 WT1 (6F-H2) 6F-H2 Succinic Dehydrogenase (SDH) CD123 7G3 LMO2 SP51 CD138 BC/B-B4 Mammaglobin 31A5 CD163 10D6 MDM2 IF2 CHROMOGENIC ISH PROBES CDX-2 CDX2-88 Melan A A103 CISH EBER CEA polyclonal MiTF C5+D5 CISH KAPPA Chromogranin A DAK-A3 MLH-1 G168-15 CISH LAMBDA Clusterin 41D MOC-31 MOC-31 CMV DDG9+CCH2 MSH-2 FE11 C-MYC Y69 MSH-6 BC/44 Cox-2 33 MUM-1 MUM1P CXCL-13 53610 Muramidase polyclonal Cyclin-D1 SP4 Myeloperoxidase polyclonal Cytokeratin 5/6 D5/16B4 MyoD1 5.8A