Prorenata Laboratories, LLC Toll Free: 1-888-680-0014 • Fax: 1-833-297-0961 8222 S. 48th Street, Suite 210 • Phoenix, Arizona 85044 Director: Joshua Bornhorst, Ph.D., DABCC, FACB CLIA# 03D2147626 PATIENT INFORMATION Last Name: ___________________________________________ First Name: _________________________________________D.O.B.____________________________ Ordering Doctors Name: __________________________________________ SPECIMEN INFORMATION FACILITY INFORMATION Date of collection (MM/DD/YY):____________________________________ Facility Name: ___________________________________________________ Time of Collection: _______________________________________________ Printed Physician Name Patient/Guardian Signature Date Physician Signature Date Patient/Guardian Signature Date Physician Signature Date ICD-10 CODES ANTIBIOTIC RESISTANCE Carcinoma in situ of cervix (D06.9) or vulva N82.1 Other female urinary-genital tract R39.89 Other and unspecified symptoms Z16.30 Resistance to unspecified (D07.1) or vagina (D07.2) fistulae and signs involving the urinary antimicrobialPatient/Guardian drugs Signature D07.30 CarcinomaDate in situ of unspecified N82.4 Other female Physicianintestinal-genital Signature tract system Date Z16.31 Resistance to antiparasitic drug(s) female genital organs ( ) D07.39 fistulae R39.9 Unspecified symptoms and signs Z16.32 Resistance to antifungal drug(s) Carcinoma in situ of other female N86 Erosion, ectropion of cervix uteri involving the GU system Z16.33 Resistance to antiviral drug(s) genital organs N87.9 Dysplasia of cervix uteri R50.9 Fever, unspecified Z16.35 Resistance to multiple antimicrobial D07.60 Carcinoma in situ of unspecified N88.0 Leukoplakia of cervix uteri R80.0 Isolated proteinuria drugs male genital organs ( ) D07.61 N89.3 Dysplasia of vagina R82.3 Hemoglobinuria Z16.39 Resistance to other specified Carcinoma in situ of scrotum N90.3 Dysplasia of vulva R82.90 Other unspecified abnormal antimicrobial drugs D07.69 Carcinoma in situ of other male N90.4 Leukoplakia of vulva findings in urine (positive nitrite or Z16.341 Resistance to single genital organs N41.0 Acute prostatitis leukocyte esterase) antimycobacterial drug N30.00 Acute cystitis without hematuria N41.1 Chronic prostatitis R87.614 Cytologic evidence malignancy, Z16.342 Resistance to multiple N30.10 Interstitial cystitis (chronic) without N41.9 Inflammatory disease of prostate, cervix or vagina (R87.624) antimycobacterial drugs hematuria unspecified R87.610 Atypical squamous cells of N30.40 Irradiation cystitis without N34.1 Nonspecific urethritis undetermined significance (ASC- GENITO-URINARY hematuria N34.3 Urethral syndrome, NOS US), cytologic smear of cervix () or A60.00 HSV of urogenital system, N30.90 Cystitis, NOS without hematuria N39.0 Urinary tract infection, site not vagina (R87.620)( ) ASC-US, can’t unspecified N70.93 Salpingitis and oophoritis, NOS specified exclude high grade squamous A60.1 HSV infection, perianal skin/rectum N71.9 Inflammatory disease of uterus, N49.9 Inflammatory disorder of intraepithelial lesion (ASC-H), cervix A60.9 Anogenital herpes viral infection, NOS unspecified male genital organ (R87.611) or vagina (R87.621) unspecified N73.9 Female pelvic inflammatory R10.2 Pelvic/perineal pain R87.612 Low grade squamous intraepithelial A63.0 Anogenital (venereal) warts disease, NOS R30.0 Dysuria lesion (LGSIL), cytologic smear of A64 Unspecified sexually transmitted N72 Inflammatory disease of cervix R30.9 Painful micturiton, unspecified cervix or vagina (R87.622) disease uteri (with or without ulcer or R31.9 Hematuria, unspecified R87.613 High grade squamous B00.9 Herpes viral infection, unspecified erosion) R35.8 Polyuria, NOS intraepithelial lesion (HGSIL), B37.3 Candidiasis, vulva/vagina N76.0 Acute vaginitis R36.9 Urethral discharge, unspecified cytologic smear of cervix or vagina B37.49 Candidiasis, other urogenital N76.1 Subacute/chronic vaginitis R35.0 Frequency of micturiton (R87.623) B37.9 Candidiasis, unspecified Ulceration of vagina (N76.5) or vulva (N76.6) R39.15 Urgency of Urination R87.810 Cervical high risk human C53.9 Malignant neoplasm of cervix uteri, N82.0 Vesicovaginal fistula R39.198 Other difficulties with micturition papillomavirus (HPV) DNA test positive unspecified N82.9 Female genital tract fistula, NOS R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive URINARY TRACT INFECTION BACTERIA Providencia Stuartii streptoccoccus agalactia (group B) tet B, tet M Escherichia coli Staphylococcus aureus* gardnerella vaginalis ermB, C; mefA Pseudomonas aeruginosa Staphylococcus (coagulase negative: FUNGAL dfr (A1, A5), sul (1,2) probes Enetrococcus faecium, faecalis epidermidis, haemolyticus, lugdunensis, Candida albicans, glabrata, parapsilosis, (Sulfamethoxazole and trimethoprim) Enterobacter aerogenes, cloacae saprophyticus) tropicalis IMP, NDM, VIM Groups (Carbapenem) Klebsiella pneumoniae/ oxytoca Staphylococcus saprophyticus STI ACT, MIR, FOX, ACC Groups (Beta Lactams) Acinobacter baumannii Streptococcus, Group A [pyogenes] trichomonas vaginalis PER-1/VEB-1/GES-1 Groups (ESBL) Proteus mirabilis, vulgaris Viridians Group Streptococcus (anginosus, neisseria gonorrhoeae VanA, VanB (Vancomycin) Prevotella bivia oralis, pasteuranus) chlamydia trachomatis Sul I Sul II Serratia marcescens Haemophilus influenzae Mycoplasma genitalium, hominis MRSA* Mec-A gene Citrobacter koseri Corynebacterium urealyticum ANTIBIOTIC RESISTANCE Class A β-lactamase; blaKPC Citrobacter freundii/braakii Mobiluncus curtissi, mobilunucs mulieris Class D oxacillinase OXA-48 Class A β-lactamase; CTX-M-Group1 Morganella Morganii Ureaplasma urealyticum, parvum Class D oxacillinase OXA--51 Class B metallo-β-lactamase; blaNDM Bacteroides fragilis qnrA1, A2, B2 qnrB & qnrS INSURANCE INFORMATION & REQUIRED ATTACHMENTS Urinary Tract Pathogens Specimen Collection Instructions DĂƚĞƌŝĂůƐWƌŽǀŝĚĞĚ ůŝŶŝĐĂůdĞĐŚŶŝĐŝĂŶ/ŶƐƚƌƵĐƟŽŶƐ EŽŶͲůĞĂŶͲĂƚĐŚWƌŽĐĞĚƵƌĞ ϭ͘WƵƚŽŶƐƚĞƌŝůĞŐůŽǀĞƐ͘ hƐŝŶŐĂƐƚĞƌŝůĞƉůĂƐƟĐƚƌĂŶƐĨĞƌƉŝƉĞƩĞ;ŶŽƚƉƌŽǀŝĚĞĚͿ ĮƌƐƚŵŽƌŶŝŶŐƐĂŵƉůĞŽƌƐĂŵƉůĞĐŽůůĞĐƚĞĚůŽŶŐĞƌƚŚĂŶϭͲϮ ŚŽƵƌƐƐŝŶĐĞƉƌŝŽƌƵƌŝŶĂƟŽŶŵĂdžŝŵŝnjĞƐƐĞŶƐŝƟǀŝƚLJŽĨĚĞƚĞĐƟŶŐ Ă͘^ǁŝƌůƚŚĞƉŝƉĞƩĞϭϬͲϭϱƟŵĞƐƚŽŵŝdžƚŚĞƐĂŵƉůĞ͘ ƵƌŝŶĂƌLJƐLJƐƚĞŵƉĂƚŚŽŐĞŶƐ͘ ď͘dƌĂŶƐĨĞƌĂƚůĞĂƐƚϮŵ>ŽĨƵƌŝŶĞĨƌŽŵƚŚĞĐŽůůĞĐƟŽŶĐƵƉ ƚŽƚŚĞŵŽůĞĐƵůĂƌƚƌĂŶƐƉŽƌƚƚƵďĞ͘ WĂƟĞŶƚ/ŶƐƚƌƵĐƟŽŶƐ Đ͘^ĞĐƵƌĞůLJƟŐŚƚĞŶƚŚĞĐĂƉŽĨƚŚĞƚƌĂŶƐƉŽƌƚƚƵďĞ͘ ϭ͘ tĂƐŚŚĂŶĚƐƚŚŽƌŽƵŐŚůLJǁŝƚŚǁĂƌŵǁĂƚĞƌĂŶĚƐŽĂƉ͘ ϯ͘WůĂĐĞĂůĂďĞůǁŝƚŚƚǁŽƉĂƟĞŶƚŝĚĞŶƟĮĞƌƐŽŶƚŚĞƚƵďĞ͘ &ĞŵĂůĞƐ͗ ,ŽůĚŝŶŐůĂďŝĂĂƉĂƌƚ͕ĐŽůůĞĐƚĮƌƐƚΕϭϬͲϮϱŵ>ƵƌŝŶĞŝŶƚŽ ϰ͘<ĞĞƉƚŚĞƚƵďĞŝŶƚŚĞƵƉƌŝŐŚƚƉŽƐŝƟŽŶĨŽƌϭϬʹϭϱŵŝŶƵƚĞƐ ƉƌŽǀŝĚĞĚƐƚĞƌŝůĞƵƌŝŶĞĐƵƉ͘ ďĞĨŽƌĞƉůĂĐŝŶŐŝƚŝŶƚŚĞƉƌŽǀŝĚĞĚƐƉĞĐŝŵĞŶďĂŐ͘ DĂůĞƐ͗ ϱ͘WůĂĐĞĂůůƐĂŵƉůĞƐĐŽůůĞĐƚĞĚĨŽƌƚŚĞĚĂLJŝŶƚŽĂƉƌŽǀŝĚĞĚhW^ͬ ZĞƚƌĂĐƚĨŽƌĞƐŬŝŶ;ĂƐĂƉƉůŝĐĂďůĞͿ͕ĐŽůůĞĐƚĮƌƐƚΕϭϬͲϮϱŵ> &ĞĚdž>ĂďWĂŬŵĂŝůĞƌ͘^ĞĂůƚŚĞŵĂŝůĞƌĂŶĚƉůĂĐĞĂƐŚŝƉƉŝŶŐůĂďĞů ƵƌŝŶĞŝŶƚŽƉƌŽǀŝĚĞĚƐƚĞƌŝůĞƵƌŝŶĞĐƵƉ͘ Ϯ͘ ^ĞĐƵƌĞůLJƉůĂĐĞĐĂƉŽŶƵƌŝŶĞĐƵƉ͕ĂŶĚŐŝǀĞƚŽƚŚĞĐůŝŶŝĐĂů ƚĞĐŚŶŝĐŝĂŶ͘ 6SJOBSZ5SBDU*OGFDUJPO /DEHO7XEHV,PPHGLDWHO\ v Must use SURYLGHGODEODEHO)LOORXWSHHOVWLFNWRWXEH v /DEHOWXEHLQ sight of patient v 3XWSDWLHQWVIXOOQDPHDQGGDWHRIELUWK v 'DWHRIFROOHFWLRQ WLPH ^W/DE^,/WDEd͗ ϭ͘ hW^^ŚŝƉŵĞŶƚƐ͗ĨƚĞƌĨŽůůŽǁŝŶŐƚŚĞƚƌĂŶƐĨĞƌͬůĂďĞůŝŶŐƐƚĞƉƐĂďŽǀĞ͕ƉůĂĐĞƚŚĞƐĂŵƉůĞƐ ŝŶƐŝĚĞƚŚĞƐƉĞĐŝŵĞŶďŝŽŚĂnjĂƌĚŽƵƐďĂŐĂŶĚĂƉƉůLJƚŚĞnjŝƉͲůŽĐŬƐĞĂů͘ 3ODFHDOOVDPSOHVLQWRLQVXODWHG 3ODFHSURSHUO\ODEHOHG 3ODFHVSHFLPHQUHTXLVLWLRQ PDLOLQJ3DNDQGVHDODWWKH VSHFLPHQVLQWRELR SDWLHQWGHPRJUDSKLFVKHHW HQGRIWKHGD\RQO\3ODFH3DN DQGLQVXUDQFHLQIRUPDWLRQ LQWR836ER[SXWVKLSSLQJ KD]DUGVDPSOHEDJV ODEHORQER[DQGSODFHLQ LQWRSDSHUZRUNSRXFKRQ GHVLJQDWHGSLFNXSORFDWLRQ EDFNRIELRKD]DUGVDPSOH EDJ.