<p> BMGDL GENETIC TEST REQUISITION FORM CLIENT ACCOUNT INFORMATION BIOCHEMICAL and MOLECULAR GENETICS DIAGNOSTIC LAB University of Miami, Department of Human Genetics Client Name: ______1501 NW 10th Ave, BRB-535 (M860), Miami, FL 33136 Fax: ______Ph. (305) 243-5450 Fax (305) 243-2407 Client No.: ______Tel:______Clients must contact the Genetics Billing Office at (305)-243-6583 to establish a Medical Record #: ______“Client Account Number” prior to forwarding specimens to the laboratory. Auth #:______For specimen pick up, test results, status, and any other technical inquiry, please call the BMGDL at 305-243-5450 SPECIMEN INFORMATION ATTENTION HEALTH CARE PROVIDERS: Medical Necessity: Federal regulators require that only tests that are necessary for diagnosis and treatment of a patient’s condition be ordered. ICD-10 Code is required to prove Collection Date: ______/______/______Time: ______am/pm medical necessity of outpatients (please enter ICD-10 code on page 2, top section). Dr.’s name, phone number and Collected By: ______ICD-10 Code are absolutely required. Specimen Source:______PLEASE PRINT ALL OF THE FOLLOWING INFORMATION. Sample type(s) submitted: EDTA Purple Top Tube Whole Blood PATIENT INFORMATION For BMGDL use only:</p><p>Last Name: ______First Name: ______Accession No.: ______Address:______City : ______Received by: ______State: ______Zip: ______Date: ______/______/______Time: ______am/pm SS#: ______/______/______Date of Birth: ______/______/______Amount of Sample: ______Sex:  M  F ICD-10 Code:______Medical Record #: Condition of Sample:______ORDERING PHYSICIAN INFORMATION (PLEASE PRINT LEGIBLY) PATIENT INSURANCE INFORMATION (IF APPLICABLE) GIBLY) INSURED: ______ HMO _  PPO _  POS Test Order Date: ______/______/______Time : ______am/pm Insurance Co: ______Ordering M.D. Name: ______Authorization # (if required) ______Ordering M.D. NPI #: ______Beeper/Ph: ______Medicaid/ Hospital/Lab Name: ______Policy #: ______Medicare#: ______Address: ______City: ______Address: ______City:______State: ______Zip: ______Tel: ______Fax: ______State: ______Zip: ______Ordering M.D. Signature: ______Tel: ______Fax: ______Relationship to Insured: ______DUPLICATE REPORT PLACE BARCODE/LABELS HERE</p><p> Physician  Genetic Counselor  Other For BMGDL use only: Last Name: ______First Name: ______Address: ______City:______</p><p>State: ______Zip: ______Tel: ______Fax: ______BIOCHEMICAL and MOLECULAR GENETICS DIAGNOSTIC LAB CPT Check Test CPT Check Test Codes Biochemical Genetics Testing Order Codes Biochemical Genetics Testing Order</p><p>TEST DESCRIPTION TEST DESCRIPTION</p><p>Acylcarnitines, Plasma 82017 84030 PKU Profile, Plasma (Lab Code 110061) (Lab Code110001) Amino Acids, Plasma (Lab Code110002) 82139 82543 Succinic Acetone, Urine (Lab Code 110070)</p><p>83921 Methylmalonic Acid, Plasma (Lab Code 110046) Total & Free Carnitine (Lab Code 110005) 82379</p><p>Methylmalonic Acid, Urine (Lab Code 110047) 83921</p><p>MSUD profile (Lab Code 110055) 82136</p><p>Organic Acids, Urine (Lab Code 110013) 83919</p><p>All Specimens must be collected and provided to laboratory. At minimum lab must receive: For Biochemical Genetics testing 2ml Green top heparinized tube at room temperature. For Biochemical Genetics Urine specimen 3ml refrigerated at 4 degrees C. For Molecular Genetics 5ml purple top EDTA tube whole blood at ROOM TEMPERTAURE. 6-2017 ODERING PHYSICIAN ASSUMES RESPONSIBILITY FOR OBTAINING APPROPRIATE INFORMED CONSENT FOR GENETIC TESTING</p><p>FLAHCA: 800026334 Provider: Dept. Human Genetics Client Notification: Clients should contact the laboratory prior to shipping any specimen emanating CLIA: 10D2031737 External Billing Area: outside of the State of Florida, to determine BMGDL licensing eligibility to accept the sample for testing. For technical assistance, please call (305)-243-5450. Please note that specimens will not be processed until Medicare:BS5872 Internal Billing Area: out of State billing functions have been approved and cleared by the UM Genetics Billing Office. Contact (305)- Tax ID No: 243-6583. Communication may also be completed via email [email protected]. 6-2017 Medicaid: 000796000 Facility: BMGDL 59-0624458</p><p>Page 1 of 1 BMGDL GENETIC TEST REQUISITION FORM</p><p>Page 2 of 1</p>