Drug Metabolism Test

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Drug Metabolism Test 285 Newton Road, 5292 CBRB Iowa City, IA 52242-1078 Iowa Institute of Human Genetics Phone: 319-335-3688 Fax: 319-335-3484 Clinical Test Requisition Form www.medicine.uiowa.edu/humangenetics/ CLIA ID 16D2053873 CAP# 8864771 Patient Information Specimen Information

Specimen Collection Date: ____ /____ / ______

MM / DD / YYYY

Specimen Type: ☐ ~6mL EDTA whole blood - Place patient ID sticker here - ☐~3mL EDTA whole blood (pediatric) MRN: Accession #: Clinical Indication for Testing: -OR-

Name: ______Last First

DOB: ____ /____ / ______Sex: ☐Male MM / DD / YYYY ☐Female ICD-10 code: Ordering Options Select one or more options: ☐Infectious disease drugs: atazanavir ☐Anti-clotting drugs: clopidogrel ☐Neurology/Psychiatry drugs: amitriptyline, aripiprazole, ☐Cancer-related drugs: 6-mercaptopurine, capecitabine, citalopram, clomipramine, desipramine, doxepin, escitalopram, fluorouracil, nilotinib, rasburicase, tegafur, thioguanine fluvoxamine, imipramine, nortriptyline, paroxetine, pimozide, ☐Immunosuppressants: azathioprine, tacrolimus sertraline, tetrabenazine, trimipramine ☐Opioids: codeine, tramadol ☐All categories Reporting Information (fax# required to send results) Payment Information ***The IIHG will NOT submit to insurance. Institutional Health Care Provider: billing or payment by credit card is accepted. NPI: Billing Contact: Institution: Institution: Street Address: Street Address: City: State: Zip: City: State: Zip: Phone: Fax: Phone: Fax: Additional Report Recipient (fax# required to send results) Race and Ethnicity Health Care Provider: Select all that apply

Billing Contact: ☐American Indian or Alaska Native ☐Asian Institution: ☐Black or African American Street Address: ☐Native Hawaiian or Other Pacific Islander ☐White City: State: Zip: Hispanic or Latino? ☐Yes ☐No Phone: Fax: Shipping Instructions • Samples will be accepted Monday-Friday. Do not ship for Saturday delivery. • Samples should be stored and shipped at ambient temperature.

IIHG ID#______For office use only

Rev. Nov 2016 If you have questions please contact the IIHG at 319-335-3688 or [email protected] Page 1 of 2

a. UIHC health care providers should complete the requisition form and place a test order as a Miscellaneous Test in Epic - titled ‘Drug Metabolism Test’. This is a send out test. b. Health care providers outside of the University of Iowa Hospitals and Clinics may order the test by mailing the completed requisition form and sample to the address listed below. 2. This test must be ordered by a health care provider. Please note, patients are not permitted to order the test. Sample requirements: 1. Either: a. 6 mL whole blood in lavender EDTA tube (3 mL pediatric minimum). Samples must be received within 72 hours of sample collection. OR b. 10 µg DNA (A260/A280 1.8-2) resuspended in 0.1mM EDTA (10mM Tris HCl, 0.1mM EDTA, pH 8, Teknova Cat# T0220) 2. All samples must be labeled with the patient's name, date of birth and date of collection. Please note: If insufficient quality or quantity of DNA is obtained, an additional sample will be requested. Incorrect handling or shipping of specimens can result in insufficient quality or quantity of DNA. Shipping requirements: • After collection, samples should be stored and shipped at room temperature • Delivery (will receive samples Monday-Friday): Iowa Institute of Human Genetics University of Iowa 285 Newton Road, 5292 CBRB Iowa City, IA 52242 Phone: 319-335-3688 Billing • Institutional billing, Visa and MasterCard are accepted • The IIHG will NOT bill insurance, Medicare or patients directly • Contact laboratory for CPT code information.

Results Reporting: • Result reports will be faxed to the referring health care provider(s) indicated on the test requisition. Please contact the IIHG lab for turnaround time information. Disclaimer: This request to order molecular diagnostic tests from the IIHG certifies to the IIHG that the ordering physician has obtained informed consent from the patient as required by applicable state or federal laws for each test ordered, that the ordering physician has authorization from the patient permitting the IIHG to report results for each test ordered to the ordering physician, and that the ordering physician assumes responsibility for providing the patient with all associated guidance and counseling regarding the test results.

Rev. Nov 2016 If you have questions please contact the IIHG at 319-335-3688 or [email protected] Page 2 of 2