British Columbia Laboratory Requisition This Requisition Form, When Completed, Constitutes a Referral to Lifelabs/BC Biomedical Laboratories Physicians

1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany British Columbia Laboratory Requisition This requisition form, when completed, constitutes a referral to LifeLabs/BC Biomedical Laboratories physicians. Please ship NON-PRENATAL SAMPLES to: LIFELABS • Attn: CDS Department 100 International Boulevard• Toronto ON• M9W6J6 Attention Patient: Please visit your nearest LifeLabs or BCBiomedical Patient Service Centre for sample collection TO BE COMPLETED BY ORDERING DOCTOR AND PATIENT Patient Name (from CareCard or other ID) Gender Date of Birth Male Female YEAR MONTH DAY Patient Address Telephone Number Patient Email Bill to Patient: ✓(no charge at PSC) Doctor Name MSC # Organization

Address Fax Number Telephone Number Email

Copy to

Genetic Test - mnemonic ACG (Blood sample 2 x 4mL EDTA)

Genetic Test (Pediatric) - mnemonic CEN (Blood sample 1 x 2mL EDTA)

Genetic Test (Other Sample Type) - mnemonic OCG (other sample type) PRENATAL SAMPLES: Please ship directly to CENTOGENE.

Privacy Statement: The personal information collected on this form is collected under the authority of the Personal Information Protection act. The personal information is used to provide medical services requested on this requisition. The information collected is used for quality assurance management and disclosed to healthcare practitioners involved in providing care or when required or permitted by law. Personal information is protected from unauthorized use and disclosure in accordance with the Personal Information Protection act and when applicable the e-health act and/or the Freedom of Information and Protection of Privacy act and may be used and disclosed only as provided by those acts. our privacy policies are available at www.bcbio.com and www.lifelabs.com.

Genetic Testing Consent I understand that a DNA specimen will be sent to LifeLabs for genetic testing. My physician has told me about the condition(s) being tested and its genetic basis. I am aware that correct information about the relationships between my family members is important. I agree that my specimen and personal health information may be sent to Centogene AG at their lab in Germany (address below). To ensure accurate testing, I agree that the results of any genetic testing that I have had previously completed by Centogene AG may be shared with LifeLabs. I understand that LifeLabs will contact me for a new specimen if a test result cannot be provided from the original specimen. I agree that a copy of my results will be sent to my ordering physician. I further agree that for any test(s) performed by Centogene AG, a copy of my results will also be sent to LifeLabs. I understand that once the requested test(s) has/have been completed, any remaining sample will be stored at the testing laboratory.

OPTIONAL CONSENT: Please Initial where appropriate

I agree that my de-identified sample may be used for product development or research purposes. I understand that I will not receive any royalties, resultant payments, benefits or rights to products or discoveries. I do not want my remaining sample to be stored. Please destroy any remaining sample once the final report has been issued. I have had genetic testing completed in the past by the following laboratories: I agree that Centogene AG and LifeLabs may obtain a copy of these genetic test results from the testing laboratory.

Patient/Substitute Decision Maker:

Signature: Date(YY/MM/DD):

Printed name: relationship to person being tested: OR I certify that verbal consent was obtained from the patient /substitute decision maker for the requested genetic testing

Signature: Date(YY/MM/DD):

For appointments at LifeLabs Patient Service Centres please call 1-855-412-4495. For appointments at BC Biomedical Patient Service Centres please call 1-877-507-5595

Date Doctor Signature

YEAR MONTH DAY TO BE COMPLETED BY LABORATORY STAFF Date /Time of Collection Phlebotomist

YEAR MONTH DAY

**Laboratory Staff: Photocopy Requisition and include one copy with samples in box** LL-GCG-001 - Ver 2 – JAN 2015

Page 1/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V3 Jan2015

GENETIC TESTING REQUISITION 1. CARDIOVASCULAR DISORDERS 1-844-363-4357 · [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD):

` Sample Type: □ *Blood (EDTA: 5mL for single gene, 10mL for panel)

□ DNA (single gene:1-10ug, panel 10-100ug)

□ *Filter card (1 card/30 exons: Available by request)

□ Saliva (Oragene OG-510: Available by request)

□ Fibroblast/Skin Biopsy (0.5cm2)

□ Cultured cells (1 flask, min 25cm2, 80-90% confluent)

□ **Amniotic fluid (10mL)

□ **Chorionic Villus (10 villi, cleaned) □ Other: ______

* Exact amount depends on size of panel, see www.centogene.com ** Please contact us prior to sending cells

Billing Status: □ Ministry of Health Approved (Approval letter attached) □ Ministry of Health Approval Pending

□ Institution (Complete information below) □ Private Pay (Complete information below)

Institution Billing ONLY: Institution Name: ______Contact Name: ______

Address:

Phone: ( ) - Fax: ( ) - Email: ______Private Pay ONLY: Credit Card Type: □ MasterCard □ Visa

Card Number______Exp Date(MM/YY)______

Name (as it appears on credit card)______I understand that my credit card will be charged for the full amount of testing not paid for by my provincial health plan

Cardholder Signature: ______Date (DD/MM/YYYY)______

Patient Information: Gender: □M □ F Ethnicity: ______Additional patient medical information:

Relevant Family history:

Have other family members submitted samples to Centogene for analysis? □Y □ N If yes, Name:______Relationship to patient ______

DOB (YYYY/MM/DD):______

Familial Mutation Testing Gene:______Mutation (HGVS):______□Familial Report attached

Testing Instructions: (ex: Reflex order) ** PLEASE INCLUDE A COPY OF REQUISITION WITH SAMPLES **

Page 2/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V3 Jan2015

GENETIC TESTING REQUISITION 1. CARDIOVASCULAR DISORDERS 1-844-363-4357 · [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD):

` Please indicate requests for Hot Spot (H), Exon (E), Sequencing (S), Repeat Expansion (R) and/or Deletion/Duplication (D) analysis

Arrhythmias

NGS Panels: (AKAP9,ANK2,CACNA1C,CACNB2,CASQ2,CAV3,DSC2,DSG2,DSP,GPD1L,JUP,KCNA5,KCNE1,KCNE2,KCNE3,KCNH2,KCNJ2,KCNQ1, D S Arrhythmia, hereditary panel NPPA,PKP2,PLN,RYR2,SCN1B,SCN3B,SCN4B,SCN5A,SNTA1,TGFB3,TMEM43) D S Brugada syndrome panel (CACNA1C, CACNB2, GPD1L, HCN4, KCNE3, SCN1B,SCN3B, SCN5A, SLMAP) Catecholaminergic polymorphic (RYR2, CASQ2, KCNJ2) D S ventricular tachycardia panel D S Long QT syndrome panel (AKAP9, ANK2, CACNA1C, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNJ5, KCNQ1, SCN4B, SCN5A, SNTA1) Single genes:

H D S Atrial fibrillation type 3 (KCNQ1) H D S Long QT syndrome type 1 (KCNQ1) D S Atrial fibrillation type 4 (KCNE2) D S Long QT syndrome type 2 (KCNH2) D S Atrial fibrillation type 6 (NPPA) H D S Long QT syndrome type 3 (SCN5A) D S Atrial fibrillation type 7 (KCNA5) D S Long QT syndrome type 4 (ANK2) H D S Atrial fibrillation type 10 (SCN5A) E D S Long QT syndrome type 5 (KCNE1) D S Atrial fibrillation type 11 (GJA5) D S Long QT syndrome type 6 (KCNE2) H D S Brugada syndrome type 1 (SCN5A) D S Long QT syndrome type 8 (CACNA1C) D S Brugada syndrome type 2 (GPD1L) H D S Long QT syndrome type 9 (CAV3) D S Brugada syndrome type 3 (CACNA1C) D S Long QT syndrome type 10 (SCN4B) D S Brugada syndrome type 4 (CACNB2) D S Long QT syndrome type 11 (AKAP9) D S Brugada syndrome type 5 (SCN1B) D S Long QT syndrome type 12 (SNTA1) D S Brugada syndrome type 6 (KCNE3) D S Long QT syndrome type 13 (KCNJ5) D S Brugada syndrome type 7 (SCN3B) D S Progressive familial heart block (TRPM4) D S Brugada syndrome type 8 (HCN4) D S Short QT syndrome type 1 (KCNH2) H D S Brugada syndrome type 9 (SLMAP) H D S Short QT syndrome type 2 (KCNQ1) H D S Catecholaminergic polymorphic Ventricular tachycardia type 1 (RYR2) D S Short QT syndrome type 3 (KCNJ2) H D S Catecholaminergic polymorphic Ventricular tachycardia type 2 (CASQ2) H D S Sick sinus syndrome type 1 (SCN5A) D S Catecholaminergic polymorphic Ventricular tachycardia type 3 (CALM2) H D S Sick sinus syndrome type 3 (MYH6) D S Catecholaminergic polymorphic Ventricular tachycardia type 4 (CALM1) H D S Sudden infant death syndrome (SCN5A) H D S Heart block type 1 (SCN5A) H D S Ventricular fibrillation, paroxysmal familial type 1 (SCN5A) H D S Jervell and Lange-Nielsen syndrome type 1 (KCNQ1) D S Ventricular tachycardia, familial (GNAI2) E D S Jervell and Lange-Nielsen syndrome type 2 (KCNE1) D S Wolff -Parkinson-White syndrome (PRKAG2)

Cardiomyopathies

NGS Panels: Arrhythmogenic right ventricular (DSP, DSG2, DSC2, JUP, PKP2, RYR2, TMEM43) D S cardiomyopathy panel Cardiomyopathy dilated panel (ABCC9, ACTC1, ACTN2, BAG3, CSRP3, DES, DMD, DSG2, EYA4, FKTN, GATAD1, LAMP2, LDB3, LMNA, MYBPC3, MYH6, MYH7, MT- D S ND1, MT-ND5, MT-ND6, MT-TD, MT-TH, MT-TI, MT-TK, MT-TL1, MT-TL2, MT-TM, MT-TQ, MT-TS1, MT-TS2, NEXN, PLN, PSEN1, PSEN2, RBM20, SCN5A, SDHA, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL) (ACTC1, CALR3, CAV3, CSRP3, GLA, JPH2, LAMP2, MYBPC3, MYH6, MYH7, MYL2, MYL3, MYLK2, MYOZ2, NEXN, PLN, PRKAG2, D S Cardiomyopathy hypertrophic panel SLC25A4, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL) Single genes:

D S Arrhythmogenic right ventricular cardiomyopathy type 1 (TGFB3) H D S Cardiomyopathy, dilated type 1D (TNNT2) D S Arrhythmogenic right ventricular cardiomyopathy type 5 (TMEM43) D S Cardiomyopathy, dilated type 1DD (RBM20) D S Arrhythmogenic right ventricular cardiomyopathy type 8 (DSP) H D S Cardiomyopathy, dilated type 1E (SCN5A) D S Arrhythmogenic right ventricular cardiomyopathy type 9 (PKP2) H D S Cardiomyopathy, dilated type 1EE (MYH6) D S Arrhythmogenic right ventricular cardiomyopathy type 10 (DSG2) E D Cardiomyopathy, dilated type 1G (TTN) D S Arrhythmogenic right ventricular cardiomyopathy type 11 (DSC2) D S Cardiomyopathy, dilated type 1HH (BAG3) D S Arrhythmogenic right ventricular cardiomyopathy type 12 (JUP) H D S Cardiomyopathy, dilated type 1I (DES) D S Barth syndrome (TAZ) D S Cardiomyopathy, dilated type 1L (SGCD) H D S Cardiomyopathy, dilated (MYBPC3) D S Cardiomyopathy, dilated type 1LL (PRDM16) H D S Cardiomyopathy, dilated type 1A (LMNA) D S Cardiomyopathy, dilated type 1M (CSRP3) D S Cardiomyopathy, dilated type 1AA (ACTN2) D S Cardiomyopathy, dilated type 1N (TCAP) D S Cardiomyopathy, dilated type 1C (LDB3) D S Cardiomyopathy, dilated type 1O (ABCC9) D S Cardiomyopathy, dilated type 1CC (NEXN)

Page 3/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V3 Jan2015

GENETIC TESTING REQUISITION CARDIOVASCULAR DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): ` Cardiomyopathies (continued)

D S Cardiomyopathy, dilated type 1P (PLN) H D S Cardiomyopathy, familial hypertrophic type 10 (MYL2) H D S Cardiomyopathy, dilated type 1R (ACTC1) H D S Cardiomyopathy, familial hypertrophic type 11 (ACTC1) H D S Cardiomyopathy, dilated type 1S (MYH7) D S Cardiomyopathy, familial hypertrophic type 12 (CSRP3) D S Cardiomyopathy, dilated type 1T (TMPO) D S Cardiomyopathy, familial hypertrophic type 16 (MYOZ2) H D S Cardiomyopathy, dilated type 1U (PSEN1) D S Cardiomyopathy, familial hypertrophic type 17 (JPH2) D S Cardiomyopathy, dilated type 1V (PSEN2) D S Cardiomyopathy, familial hypertrophic type 19 (CALR3) D S Cardiomyopathy, dilated type 1W (VCL) H D S Cardiomyopathy, familial restrictive type 1 (TNNI3) D S Cardiomyopathy, dilated type 1X (FKTN) E D S Cardiomyopathy, fatal (MT-TI) H D S Cardiomyopathy, dilated type 1Y (TPM1) D S Cardiomyopathy, hypertrophic, midventricular, digenic (MYLK2) H D S Cardiomyopathy, dilated type 1Z (TNNC1) E D S Cardiomyopathy, idiopathic dilated, mitochondrial (MT-TH) H D S Cardiomyopathy, dilated type 2A (TNNI3) H D S Fabry disease (GLA) D S Cardiomyopathy, dilated type 2B (GATAD1) D S Danon disease (LAMP2) D S Cardiomyopathy, dilated type 3B (DMD) H D S McKusick-Kaufman-Syndrome (MKK) D S Cardiomyopathy, dilated type J (EYA4) E D S MELAS syndrome (MT-TF) D S Cardiomyopathy, dilated with woolly hair and keratoderma (DSP) E D S MELAS syndrome (MT-TL1) H D S Cardiomyopathy, familial hypertrophic (CAV3) E D S MERRF syndrome (MT-TK) H D S Cardiomyopathy, familial hypertrophic type 1 (MYH7) E D S MERRF/MELAS overlap syndrome (MT-TS1) H D S Cardiomyopathy, familial hypertrophic type 2 (TNNT2) E D S MERRF/MELAS overlap syndrome (MT-TS2) H D S Cardiomyopathy, familial hypertrophic type 3 (TPM1) D S Mitochondrial myopathy and sideroblastic anemia type 1 (PUS1) H D S Cardiomyopathy, familial hypertrophic type 4 (MYBPC3) E D S Mitochondrial myopathy, isolated (MT-TD) D S Cardiomyopathy, familial hypertrophic type 6 (PRKAG2) E D S Myopathy (MT-TQ) H D S Cardiomyopathy, familial hypertrophic type 7 (TNNI3) D S Myopathy, lactic acidosis, and sideroblastic anemia type 2 (YARS2) D S Cardiomyopathy, familial hypertrophic type 8 (MYL3) D S Myopathy, mitochondrial (MT-TM) E D Cardiomyopathy, familial hypertrophic type 9 (TTN) D S Sengers syndrome (AGK)

Vascular NGS Panels: (MYH11, ACTA2, TGFBR1, TGFBR2, FBN1, COL3A1, SMAD3, CBS, FBN2, SLC2A10, MYLK, TGFB2) D S Aortic aneurysm, hereditary thoracic panel (COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, FKBP14, PLOD1, TNXB) D S Ehlers-Danlos syndrome panel Marfan syndrome and related disorders panel (ACTA2,COL3A1,COL5A1,COL5A2,FBN1,FBN2,MYH11,SLC2A10,SMAD3,TGFBR1, TGFBR2) D S Single genes: D S Angioedema, hereditary (SERPING1) D S Ehlers-Danlos syndrome type 1/2 (COL5A2) D S Antithrombin III deficiency (SERPINC1) H D S Ehlers-Danlos syndrome type 3 (COL3A1) D S Aortic Aneurysm, familial thoracic type 1 (MYH11) H D S Ehlers-Danlos syndrome type 4 (COL3A1) H D S Aortic Aneurysm, familial thoracic type 1 (TGFBR1) D S Ehlers-Danlos syndrome type 4 (COL5A1) D S Aortic Aneurysm, familial thoracic type 1 (TGFBR2) H D S Fabry disease (GLA) D S Aortic Aneurysm, familial thoracic type 1 (FBN1) D S Glycoprotein Ia C807T polymorphism (ITGA2) D S Aortic aneurysm, familial thoracic type 6 (ACTA2) H D S Homocystinuria (CBS) D S Aortic Aneurysm, familial thoracic type 7 (MYLK) D S Homocystinuria (MTHFR) D S Aortic valve disease type 1 (NOTCH1) D S Homocystinuria, B12-responsive (MTR) D S Aortic valve disease type 2 (SMAD6) D S Homocystinuria-megaloblastic anemia, cbl E type (MTRR) D S Arterial calcification type 1, generalized, infantile (ENPP1) D S Hypertension, ADD2-related(ADD2) D S Arterial Hypertension, idiopathic pulmonary (BMPR1B) D S Hypertension early onset (NR3C2) D S Arterial Tortuosity Syndrome (SLC2A10) D S Loeys-Dietz syndrome type 1C (SMAD3) D S Bernard Soulier syndrome type A1 (GP1BA) D S Loeys-Dietz syndrome type 2A (TGFBR1) D S Bernard Soulier syndrome type A2 (GP1BA) D S Loeys-Dietz syndrome type 2B (TGFBR2) D S Bernard Soulier syndrome type B (GP1BB) D S Loeys-Dietz syndrome type 4 (TGFB2) D S Bernard Soulier syndrome type C (GP9) D S Hypertension early onset (NR3C2) D S Bicuspid aortic valve (TIMP1) D S Loeys-Dietz syndrome type 1C (SMAD3) H D S CADASIL (NOTCH3) D S Loeys-Dietz syndrome type 2A (TGFBR1) D S Capillary malformations, congenital (GNAQ) D S Loeys-Dietz syndrome type 2B (TGFBR2) D S Capillary malformations-arteriovenous malformation (GNAQ) D S Loeys-Dietz syndrome type 4 (TGFB2) D S CARASIL (HTRA1) H D S Marfan syndrome (FBN1) D S Cerebral cavernous malformations type 1 (KRIT1) D S Mitochondrial myopathy and sideroblastic anemia 1 (PUS1) D S Cerebral cavernous malformations type 2 ((CCM2) H D S Moyamoya disease type 2 (RNF213) D S Cerebral cavernous malformations type 3 (PDCD10) D S Myoglobinuria acute recurrent (LPIN1) Coronary artery disease in familial hypercholesterolemia, protection against Myopathy with lactic acidosis hereditary (ISCU) D S (RASA1) D S D S Ehlers-Danlos syndrome type 1/2 (COL5A1)

Page 4/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V3 Jan2015

GENETIC TESTING REQUISITION CARDIOVASCULAR DISORDERS 1-844-363-4357· [email protected] Schillingallee 68 · 18057 Rostock Germany Patient Name: Patient DOB (YYYY/MM/DD): ` Vascular (continued)

D S Orthostatic intolerance (SLC6A2) D S Protein S Deficiency, AD (PROS1) D S Parkes Weber syndrome (RASA1) D S Pseudohypoaldosteronism type 2D (KLHL3) D S Plasminogen activator inhibitor type 1 (SERPINE1) D S Pseudohypoaldosteronism type 2E (CUL3) D S Polyarteritis nodosa, childhood-onset (CECR1) D S Sturge-Weber syndrome (GNAQ) D S Protein C Deficiency, AD (PROC) D S Supravalvar aortic stenosis (ELN)

Other

NGS Panels:

D S Central hypoventilation syndrome panel (RET, GDNF, EDN3, BDNF, ASCL1, PHOX2A, PHOX2B, ZEB2, GFRA1, ECE1, MECP2) D S Heterotaxy panel ( ACVR2B, CFC1, CRELD1, GJA1, GDF1, FOXH1, LEFTY2, NKX2-5, NODAL, ZIC3) D S Noonan – Cardiofaciocutaneous syndrome panel (BRAF, CBL, HRAS, MAP2K1, KRAS, MAP2K2, NF1, NRAS, RAF1, PTPN11, SHOC2, SOS1, SPRED1) Single genes:

D S Alveolar capillary dysplasia with misalignment of pulmonary veins (FOXF1) D S CHARGE syndrome (CHD7) D S Atrial septal defect type 2 (GATA4) D S Coarctation of the aorta (MCTP2) H D S Atrial septal defect type 3 (MYH6) D S Costello syndrome (HRAS) D S Atrial septal defect type 9 (GATA6) D S Diaphragmatic hernia type 3 (ZFPM2) D S Atrial septal defect with atrioventricular conduction defects (NKX2-5) D S DiGeorge (22q11.2 deletion) syndrome (TBX1) D S Atrioventricular septal defect, partial with heterotaxy syndrome (CRELD1) D S Dopamine beta-hydroxylase (DBH) deficiency (DBH) D S Atrioventricular septal defect type 5 (GATA6) D S Heterotaxy, visceral type 1 (ZIC3) D S Cardiac defects, CNOT3 related (CNOT3) D S Heterotaxy, visceral type 2 (CFC1) D S Cardiac valvular dysplasia, X-linked (FLNA) D S Heterotaxy, visceral type 4 (ACVR2B) D S Cardioencephalomyopathy, fatal infantile: cytochrome c oxidase def'cy (SCO2) D S Heterotaxy, visceral type 5 (NODAL) D S Cardiofaciocutaneous syndrome (KRAS) H D S LEOPARD syndrome 3 (BRAF) H D S Cardiofaciocutaneous syndrome (BRAF) D S Noonan syndrome like (SHOC2) D S Cardiofaciocutaneous syndrome (MAP2K1) D S Noonan syndrome type 1 (PTPN11) D S Cardiofaciocutaneous syndrome (MAP2K2) D S Noonan syndrome type 3 (KRAS) D S Congenital heart disease and transposition of the great arteries (FOXH1) D S Noonan syndrome type 4 (SOS1) H D S Central hypoventilation syndrome, congenital (RET) D S Noonan syndrome type 5 (RAF1) D S Central hypoventilation syndrome, congenital (GDNF) H D S Noonan syndrome type 6 (NRAS) D S Central hypoventilation syndrome, congenital (EDN3) H D S Noonan syndrome type 7 (BRAF) Noonan syndrome-like disorder with or without juvenile meylomonocytic D S Central hypoventilation syndrome, congenital (BDNF) D S leukemia (CBL) D S Central hypoventilation syndrome, congenital (ASCL1) D S Pancreatic agenesis and congenital heart defects (GATA6) D S Central hypoventilation syndrome, congenital (PHOX2A) D S Pulmonary fibrosis, idiopathic (SFTPA1) D S Central hypoventilation syndrome, congenital (ZEB2) D S Pulmonary newborn hypertension (CRHR1) D S Central hypoventilation syndrome, congenital (GFRA1) D S Tetralogy of Fallot (ALDH1A2) D S Central hypoventilation syndrome, congenital (ECE1) D S Tetralogy of Fallot (GATA6) H D S Central hypoventilation syndrome, congenital (MECP2) D S Tetralogy of Fallot ( ZFPM2) R S Central hypoventilation syndrome with or without Hirschsprung disease (PHOX2B) D S Transposition of great arteries, dextro-looped 3 (GDF1)

Page 5/5 The minimum amount of patient information is collected for provision of the service requested. This information is considered confidential and privileged. Unauthorized use and disclosure is prohibited. Requisition V3 Jan2015