HEART INSTITUTE DIAGNOSTIC LABORATORY- CARDIOMYOPATHY TEST REQUISITION
Patient label Cincinnati Children’s Hospital Medical Center 240 Albert Sabin Way, Room S4.381
Cincinnati, OH 45229-3039
Phone: 513-803-1751 Fax: 513-803-1748 Email: [email protected] Specimen type: (MM/DD/YYYY)
Blood DNA Other ______Date Collected ______Phone: 513-803-1751 Fax: 513-803-1748 PATIENT INFORMATION
First Name______MI ______Last Name______Email: [email protected] M F Unknown
DOB ______Street Address ______
City, State, Zip Code ______
Race: Ethnicity:
White Hispanic
Native American Indian or Alaska Native Ashkenazi Jewish
Asian
Native Hawaiian or Other Pacific Islander Other ______
Black or African American (check all that apply)
GENE TEST TO BE PERFORMED
Comprehensive Cardiomyopathy Panel (37 genes) ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CAV3, CRYAB, Titin Sequencing CSRP3, DES, EMD, LAMP2, LMNA, MYBPC3, MYH6, MYH7, MYL2, MYL3, MYPN, NEBL, NEXN, PLN, PRKAG2, RBM20, SCN5A, SCO2, SGCD, SURF1, Reflex to Comprehensive Cardiomyopathy Analysis if TAZ, TCAP, TNNC1, TNNI3, TNNT2, TPM1, TTN, TTR, VCL, ZASP/LDB3 targeted disease testing is normal Hypertrophic Cardiomyopathy Panel DCM & DMD Related Cardiomyopathy Panel* (23 genes) ACTC1, ACTN2, ANKRD1, CAV3, CSRP3, LAMP2, MYBPC3, MYH6, MYH7, MYL2, MYL3, NEXN, PLN, PRKAG2, SCO2, (31 genes) ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CRYAB, CSRP3, SURF1, TNNC1, TNNI3, TNNT2, TPM1, TTR, VCL, ZASP/LDB3 DES, DMD, EMD, LAMP2, LMNA, MYBPC3, MYH6, MYH7, MYPN, NEBL, NEXN, PLN, RBM20, SCN5A, SGCD, TAZ, TCAP, TNNC1, TNNI3, TNNT2, Dilated Cardiomyopathy Panel TPM1, TTN, VCL, ZASP/LDB3 *Sequencing and Del/Dup Analysis (30 genes) ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CRYAB, CSRP3, DES, EMD, LAMP2, LMNA, MYBPC3, MYH6, MYH7, MYPN, NEBL, NEXN, PLN, RBM20, SCN5A, SGCD, TAZ, TCAP, TNNC1, TNNI3, TNNT2, TPM1, Known Familial Mutation Test TTN, VCL, ZASP/LDB3 Gene______
Left Ventricular Noncompaction Mutation______(13 genes) ACTC1, ACTN2, DES, LMNA, MYBPC3, MYH7, MYL2, Name of Proband______MYL3, TAZ, TNNT2, TPM1, VCL, ZASP/LDB3 Relationship to Proband______Please provide copy of report if testing Restrictive Cardiomyopathy done at another laboratory. (9 genes) ACTC1, BAG3, CRYAB, DES, MYBPC3, MYH7, TNNI3, TNNT2, TTR
CLINICAL INFORMATION
Clinical Features – Cardiomyopathy (check all that apply)
Devices/surgeries ICD Pacemaker Ventricular enlargement/dilation Transplant Left ventricular non-compaction Skeletal muscle involvement Reduced ejection fraction/endocardial Learning difficulties shortening fraction Cardiac findings Atrial enlargement Left ventricular hypertrophy Asymmetric septal hypertrophy Concentric hypertrophy 1 of 3 Ventricular enlargement/dilation
Clinical diagnosis: Cardiomyopathy Conduction system disease HCM WPW DCM AV block ______RCM Other ______LVNC Other systemic involvement Danon disease ______Barth syndrome Leigh syndrome Age at diagnosis______
HEART INSTITUTE DIAGNOSTIC LABORATORY-TEST REQUISITION
Patient label Cincinnati Children’s Hospital Medical Center 240 Albert Sabin Way, Room S4.381 Cincinnati, OH 45229-3039 Phone: 513-803-1751 Fax: 513-803-1748
Family History Family History No Family History Patient adopted CLIA # 36D2003208 List affected family members ______Pedigree: Phone: 513-803-1751 Fax: 513-803-1748
CLIA # 36D2003208 Phone: 513-803-1751 Fax: 513-803-1748
Paternal ethnicity:______Maternal ethnicity:______Consanguinity Yes No
TEST INDICATION
Positive Family History Suspected Diagnosis Other______
REFERRING PHYSICIAN INFORMATION
Physician Name______Institution______Specialty ______Phone/Fax______Address ______City, State, Zip ______Email Address ______Contact Person (i.e. Genetic Counselor)______Phone ______Fax ______Fax duplicate reports to______
Required: Authorized Signature______
2 of 3 HEART INSTITUTE DIAGNOSTIC LABORATORY-PAYMENT INFORMATION
Patient label Cincinnati Children’s Hospital Medical Center 240 Albert Sabin Way, Room S4.381 Cincinnati, OH 45229-3039 Phone: 513-803-1751 Fax: 513-803-1748
PATIENT INFORMATION CLIA # 36D2003208
First Name______MI ______Last Name______Phone: 513-803-1751 M F Unknown Fax: 513-803-1748 DOB ______Street Address ______CLIA # 36D2003208 City, State, Zip Code ______Phone: 513-803-1751 Fax: 513-803-1748
ONE OF THE FOLLOWING BILLING OPTIONS MUST BE INDICATED.
The Patient Pay option must include payment with the sample. The Direct Insurance Billing option must include a copy of the insurance card with the requisition.
Referring Facility______
Bill to name______and/or Department______
Facility address______
Contact name ______Phone number______
Institution code ______Fax number______
Patient Pay Credit card Check
Name (as it appears on credit card)______Expiration Date ______
Credit Card Type Visa Mastercard Other ______
Credit Card Number ______3 Digit Security Code ______
Insurance Company*______
Subscriber ID: ______Group Name/Number:______
Subscriber Name, Address and Phone number: ______
______
Ordering Physician Name and NPI #: ______
Diagnosis Code(s):______
*Please note, Cincinnati Children’s Hospital Medical Center cannot bill out of state Medicaid.
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