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*Fax number given must be from a fax machine that complies with applicable HIPAA regulation. New York State Patients: Informed Consent for Genetic Testing ICD-10 Diagnosis Code “I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on file with this office Note: It is the client’s responsibility to maintain documentation of the order. or the individual’s provider’s office.” New York State Patients: Informed Consent for Genetic Testing Signature MCL Internal Use Only Note: It is the client’s responsibility to maintain documentation of the order.

Ship specimens to: Billing Information Mayo Laboratories • An itemized invoice will be sent each month. 3050 Superior Drive NW • Payment terms are net 30 days. Rochester, MN 55901 Call the Business Office with billing related questions: Customer Service: 855-516-8404 800-447-6424 (US and Canada) 507-266-5490 (outside the US) Visit www.MayoClinicLabs.com for the most up-to-date test and shipping information. T728 ©2021 Mayo Foundation for and Research Page 1 of 3 MC0767-10Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No.

Patient Name (Last, First, Middle) Client Order No.

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INFLAMMATORY BOWEL DISEASE (IBD) IGA Immunoglobulin A (IgA), Serum HELICOBACTER PYLORI Diagnosis IGG Immunoglobulin G (IgG), Serum UBT Helicobacter pylori Breath Test CALPR Calprotectecin, Feces IGM Immunoglobulin M (IgM), Serum HELIS Helicobacter pylori Culture with Antimicrobial Susceptibilities, Varies IBDP2 Inflammatory Bowel Disease Serology IMMG Immunoglobulins (IgG, IgA, and IgM), Panel, Serum Serum HPFRP Helicobacter pylori with Clarithromycin Resistance Prediction, Therapeutic Drug Monitoring TSTGP Tissue Transglutaminase Antibodies, Molecular Detection, PCR, Feces ADALX Adalimumab Quantitative with Reflex IgA and IgG Profile, Serum with to Antibody, Serum TTGA Tissue Transglutaminase Antibody, IgA, HPCRP Helicobacter pylori Serum Clarithromycin Resistance Prediction, FCZAC Certolizumab and Anti-Certolizumab Molecular Detection, PCR, Varies Antibody, DoseASSURE CTZ TTGG Tissue Transglutaminase Antibody, IgG, INFXR Infliximab Quantitation with Reflex Serum MOTILITY DISORDERS to Antibodies to Infliximab, Serum GID2 Autoimmune Gastrointestinal Dysmotility TPMT3 Thiopurine Methyltransferase Activity Evaluation, Serum Profile, Erythrocytes Clostridium difficile TPNUQ Thiopurine Methyltransferase (TPMT) CDFRP Clostridioides difficile Toxin, and Nudix Hydrolase (NUDT15) Molecular Detection, PCR, Feces Acute/Chronic Genotyping, Varies CDIF Closrtidioides difficile Culture, Varies AHEP Acute Hepatitis Profile, Serum Thiopurine Metabolites, Whole Blood THIO GI Pathogens CHSBP Chronic Hepatitis Profile (Type B), Serum Ustekinumab Quantitation USTEK GIP Gastrointestinal Pathogen Panel, PCR, CRHEP Chronic Hepatitis (Unknown Type), Serum with Antibodies, Serum Feces PHEP Previous Hepatitis (Unknown Type), Serum VEDOL Vedolizumab Quantitation with Reflex CYCL Cyclospora Stain to Antibodies, Serum Hepatitis A CRYPS Cryptosporidium Antigen, Feces VEDOZ Vedolizumab Quantitation with Antibodies, HAIGG Hepatitis A IgG Antibody, Serum GIAR Giardia Antigen, Feces Serum HAIGM Hepatitis A IgM Antibody, Serum OAP Parasitic Examination Monogenic IBD FHASQ Hepatitis A Qualitative PCR HAV SuperQual OAPNS Ova and Parasite, Microscopy, Varies IBDGP Inflammatory Bowel Disease Primary Immunodeficiency (PID) Panel, Varies PARID Parasite Identification, Varies HBIM Hepatitis B Core Antibody, IgM, Serum PINW Pinworm Exam, Perianal CELIAC DISEASE HBC Hepatitis B Core Total Antibodies, Serum ROTA Rotavirus Antigen, Feces Cascades CORAB Hepatitis B Core Total Antibodies, with STFRP Shiga Toxin, Molecular Detection, PCR, CDSP Celiac Disease Serology Cascade, Serum Reflex to Hepatitis B Core Antibody IgM, Feces Serum Celiac Disease Comprehensive Cascade, CDCOM STL Enteric Pathogens Culture, Feces Serum and Whole Blood HEAB Hepatitis B e Antibody, Serum WHIPB Tropheryma whipplei, Celiac Disease Gluten-Free Cascade, HEAG Hepatitis B e Antigen and CDGF Molecular Detection, PCR, Blood Serum and Whole Blood Hepatitis B e Antibody, Serum LCMSP Microsporidia species, Individual Tests EAG Hepatitis B e Antigen, Serum Molecular Detection, PCR, Varies FAEAB Anti-Enterocyte Antibodies HBABT Hepatitis B Surface Antibody Monitor, TWRP Tropheryma whipplei, Post-Transplant, Serum CELI Celiac Associated HLA-DQ Alpha 1 Molecular Detection, PCR, Varies and DQ Beta 1 DNA Typing, Blood HBABE Hepatitis B Surface Antibody, Employee, UREDF Reducing Substance, Feces Serum EMA Endomysial Antibodies, IgA, Serum BILE ACID HBABY Hepatitis B Perinatal Exposure Follow-up EMAIG Endomysial Antibodies, IgG, Serum Panel, Serum 7AC4 7AC4, Bile Acid Synthesis, Serum DGLDN Gliadin (Deamidated) Antibodies HBAB Hepatitis B Surface Antibody, Qualitative/ Evaluation, IgG and IgA, Serum BA48F Bile Acids, Bowel Dysfunction, 48 Hour, Quantitative, Serum Feces DAGL Gliadin (Deamidated) Antibody, IgA, HBAG Hepatitis B Surface Antigen, Serum Serum BAFS Bile Acids, Fractionated and Total, Serum HBAGP Hepatitis B Surface Antigen Prenatal, DGGL Gliadin (Deamidated) Antibody, IgG, BAPS Bile Acid Profile, Serum Serum Serum BILEA Bile Acids, Total, Serum HBVQN Hepatitis B Virus (HBV) DNA Detection and FATF Fat, Feces Quantification by Real-Time PCR, Serum FBAC Bile Acids, Urine HBGCD Hepatitis B Surface Antigen for Cadaveric or Hemolyzed Specimens, Serum

T728 Page 2 of 3 MC0767-10Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No.

Patient Name (Last, First, Middle) Client Order No.

Birth Date (mm-dd-yyyy)

Hepatitis C HEPATOCELLULAR CARCINOMA (HCC) PANCREATIC HCVL Virus Antibody Confirmation, HCCGS Hepatocellular Carcinoma Risk Panel with AMLPC Amylase, Pancreatic Cyst Fluid Serum GALAD Score, Serum; Includes: HCCDD Hepatitis C Virus Antibody in Cadaveric • AFP-L3% and total alpha fetoprotein COLON CANCER • Des-gamma-carboxy prothrombin or Hemolyzed Specimens, Symptomatic, APCZ APC Gene, Full Gene Analysis, Varies Serum • GALAD Score calculation FOBT Fecal Occult Blood, Colorectal Cancer Alpha-Fetoprotein (AFP) L3% and Total, HCCAD Hepatitis C Virus Antibody Screen for L3AFP Screen, Qualitative, Immunochemical, Hepatocellular Carcinoma Tumor Marker, Cadaveric or Hemolyzed Specimens, Feces Asymptomatic, Serum Serum LYNCH Lynch Syndrome Panel, Varies HCVG Hepatitis C Virus Genotype, Serum DCP Des-Gamma-Carboxy Prothrombin (DCP), Serum TMSI Microsatellite Instability, Tumor HCVSP Hepatitis C Virus (HCV) Antibody Screen ML1HM MLH1 Hypermethylation Analysis, Tumor Prenatal, Serum AUTOIMMUNE DISEASE MYHZ MUTYH Gene, Full Gene Analysis, Varies HCSRN Hepatitis C Virus (HCV) Antibody ALDG Autoimmune Panel, Serum Screen with Reflex to HCV RNA, PCR, Includes: PTENZ PTEN Gene, Full Gene Analysis, Varies Asymptomatic, Serum • Mitochondrial antibodies (M2) RASFP RAS/RAF Targeted Gene Panel by HCVDX Hepatitis C Virus (HCV) Antibody with • Smooth muscle antibodies screen Next-Generation Sequencing, Tumor Reflex to HCV RNA, PCR, Symptomatic, • Antinuclear antibodies (ANA) Serum AMA Mitochondrial Antibodies (M2), Serum Hepatitis C Virus (HCV) RNA Detection HCVQN SMAS Smooth Muscle Antibody Screen, Serum PATHC Pathology Consultation and Quantification, Real-Time Reverse Note: Reflex to Smooth Muscle Transcription-PCR, Prenatal, Serum Antibody Titer, Serum, if positive Hepatitis C Virus (HCV) RNA Quantification HCVQG ANA2 Antinuclear Antibodies (ANA), Serum Our full menu of allergy testing can be viewed at with Reflex to HCV Genotype, Serum gi.testcatalog.org LKM Liver/Kidney Microsome Type 1 Hepatitis D Antibodies, Serum GENETICS AHDV Hepatitis D Virus Total Antibodies, Serum A2M Alpha-2-Macroglobulin, Serum Our full menu of genetics testing can be viewed at FSLAA Soluble Liver Antigen (SLA) Autoantibody genetics.testcatalog.org HEVG Hepatitis E Virus IgG Antibody, Serum HEVM Hepatitis E Virus IgM Antibody Screen ALPHA-1-ANTITRYPSIN (A1A) DEFICIENCY with Reflex to Confirmation, Serum A1ALC Alpha-1-Antitrypsin Proteotype S/Z HEVML Hepatitis E Virus IgM Antibody by LC-MS/MS, Serum Confirmation, Serum A1APP Alpha-1-Antitrypsin Phenotype, Serum Alpha-1-Antitrypsin, Serum NONALCOHOLIC FATTY ACID DISEASE AAT A1AFS Alpha-1-Antitrypsin Clearance, FIBRO FibroTest-ActiTest, Serum Feces and Serum NSFIB Nonalcoholic Steatohepatitis (NASH)- SERPZ SERPINA1 Gene, Full Gene Analysis, Varies FibroTest, Serum and Plasma

WILSON DISEASE LYSOSOMAL ACID LIPASE DEFICIENCY LALB Lysosomal Acid Lipase, Blood CERS Ceruloplasmin, Serum LALBS Lysosomal Acid Lipase, Blood Spot CUCRU Copper/Creatinine Ratio, Random, Urine CUS Copper, Serum CUT Copper, Liver Tissue AMBF Amylase, Body Fluid CUU Copper, 24 Hour, Urine FAMYS Amylase, Isoenzymes WDZ Wilson Disease, Full Gene Analysis, Varies PAMY Amylase, Pancreatic, Serum FELAS Elastase, Pancreatic, Serum HPPAN Panel, Varies ELASF Pancreatic Elastase, Feces

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