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 ) ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CAV3, CRYAB, 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, 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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