Immunohistochemistry and Special Stain Requisition Phone 866.776.5907/ Fax 239.690.4237 neogenomics.com Client Information Patient Information Required Information Account #: __________________ Account Name: ____________________________________ Last Name: _________________________________________________ □ Male □ Female Street Address: ________________________________________________________________ First Name: ___________________________ M.I. _____ Other Pt ID/Acct #: ________________ ________________________________________________________________ Date of Birth: mm ________ / dd ________ / yyyy __________ Medical Record #: _________________ City, ST, ZIP: ___________________________________________________________________ Client represents it has obtained informed consent from patient to perform the services described herein. Phone: _________________________________ Fax: __________________________________ Specimen Information Requisition Completed by: _______________________________________ Date: ______________ Ordering Physician (please print: Last, First): ____________________________ NPI #: ______________ Specimen ID: _________________________ Block ID: ________________________________ Fixative/Preservative: _____________________________________________________________ Treating Physician (please print: Last, First): _____________________________NPI #: ______________ The undersigned certifies that he/she is licensed to order the test(s) listed below and that such test(s) are medically necessary for Collection Date: mm ________ / dd ________ / yyyy ___________ Collection Time: _______ □ AM □ PM the care/treatment of this patient. Retrieved Date: mm ________ / dd ________ / yyyy ___________ Authorized Signature: ___________________________________________Date: ______________ Hospital Discharge Date: mm ________ / dd ________ / yyyy ___________ Billing Information Body Site: ____________________________________________________________________ Primary Metastasis – If Metastasis, list Primary: ____________________________________ Required: Please include face sheet and front/back of patient's insurance card. □ □ Patient Status (Must Choose 1): □ Hospital Patient (in) □ Hospital Patient (out) □ Non-Hospital Patient □ FNA cell block: _______________________________________________________________ Bill to: □ Client Bill □ Insurance □ Medicare □ Medicaid □ Patient/Self-Pay □ Smears: Air Dried ________ Fixed ________ Stained (type of stain) ____________________ Split Billing - Client (TC) and Insurance (PC) OP Molecular to MCR, all other testing to Client □ □ □ Slides # _________ Unstained _________ Stained ________ □ H&E _________________ □ Bill charges to other Hospital/Facility: ________________________________________________________ □ Paraffin Block(s) #: ____________ □ Choose best block (global testing only) P r i o r A u t h or i z a t i o n # ____________________________________ See the NeoGenomics.com Billing section for more info. □ Perform tests on all blocks Clinical Information Breast Marker & Gastric/GEA HER2 Fixation (CAP/ASCO Requirement) Cold ischemic time ≤ 1 hour: Yes No Unknown Required: Please attach patient's pathology report (required), clinical history, and other applicable report(s). 10% neutral buffered formalin: Yes No Unknown ICD 10 (Diagnosis) Code/Narrative (Required):________________________________________ HER2/ER/PgR Fixation duration 6 to 72 hours: Yes No Unknown Reason for Referral: ____________________________________________________________________________________ □ New Diagnosis □ Relapse □ In Remission □ Monitoring G - Global G-IA - Global with Image Analysis T - Tech-Only/Stain-Only T-IA - Tech-Only with Image Analysis Staging: □ 0 □ I □ II □ III □ IV Note: ________________________ T-SQnt - Tech-Only with Semi-Quantitative interpretation by client Consultation - A NeoGenomics pathologist will select medically necessary tests with Tech-Only Qualitative IHC/ISH/Special Stains Bold indicates global prognostic interpretation is available. any exception noted below by the client to provide comprehensive analysis and professional Check here to add interpretation for the materials submitted. Performed on FFPE only. □ Surgical Pathology Consult (FFPE only) □ Add NeoTYPE® Profile if indicated AAT CD15 D240 LMO2 PD1 Special Stains Differential Diagnosis: __________________________________________________________________ ACTH CD19 DBA.44 Lysozyme PD1 (non-heme) G T AFP CD20 Desmin MAL Perforin N/A □ Alcian Blue Image Analysis/Semi-Quantitative IHC Albumin RNA ISH CD21 DOG1 Mammaglobin PgR □ □ Calcium Stain G-IA T-IA T-SQnt G-IA T-IA T-SQnt ALK-1 (Heme) CD22 DPC4 MDM2 PIT1 N/A □ Colloidal Iron □ □ □ AR □ □ □ MLH1 Annexin A1 CD23 EBV (LMP1) Melan A (Mart1) PLAP N/A □ Congo Red □ □ □ ER □ □ □ MSH2 AR CD25 E-Cadherin Melan A/Ki67 PRAME N/A □ Copper Stain □ □ □ HER2 Breast** □ □ □ MSH6 Arginase 1 CD30 EMA Melanoma Micromets Prolactin N/A □ Elastic Stain □ □ □ Ki67 □ □ □ PMS2 ATRX CD31 ER (HMB45 with Melan A/ Prostate Triple Stain N/A □ Fontana Masson □ □ □ PgR B72.3 CD33 ERG Mart1) PSA N/A □ Giemsa □ □ □ p53 BAP1 CD34 Factor VIII RA Mesothelin PSAP/HPAP N/A □ Iron **For global HER2 IHC with result 2+, NeoGenomics BCA-225 CD35 Factor XIIIa Mismatch Repair (MMR) PSMA □ □ MPO Cytochemical will add global HER2 FISH unless marked here: □ Do not reflex 2+ BCL1/Cyclin D1 CD38 Fascin MLH1 PTH N/A □ Mucicarmine Semi-Quantitative BCL1/Cyclin D1 CD42b Fli-1 MSH2 RCC1 N/A PAS MSH6 □ G T G T G T (non-heme) CD43 FOXP1 S100 N/A □ PASD BCL2 CD44 FOXP3 PMS2 S100p Periodic Acid Schiff □□ BRCA1 □□ Ki67 NET □□ PD-L1 SP263 FDA All 4 Stains □ □ □□ cMET □□ p21 (IMFINZI®)* BCL2 CD45 (LCA) FSH SALL4 with Digestion □□ COX2 □□ p27 □□ pHistone H3 (PHH3) (non-heme) CD45RO Galectin 3 MITF SATB2 (PASD+PAS) EGFR pAKT PTEN BCL2 (SP66) CD56 GATA3 MOC31 Serotonin N/A □ Reticulin □□ □□ □□ MPO N/A ERCC1 PD-L1 22C3 FDA (KEYTRUDA®) Retinoblastoma BCL6 CD57 GATA3 (heme) SF1 □ Trichrome □□ *□□ MSA N/A HER2 Colorectal^ Cervical Protein (RB) BCL10 CD61 GCDFP15 SMA □ Wright Giemsa □□ □□ MUC1 □□ HER2 Gastric/GEA** □□ ESCC (Esophageal) □□ RRM1 BerEP4 CD68 GCET1 SMMHC □□ HER2 (Other)** □□ Gastric/GEA □□ TOPO1 Beta Catenin CD68 (PG-M1) GFAP MUC2 Smoothelin In-Situ Hybridization □ Breast Scoring (Default) □□ HNSCC (Head & Neck) □□ Thymidylate BG8 CD71 GH MUC4 Somatostatin (Tech-Only) or NSCLC Synthase BOB1 CD79a Glucagon MUC5 SSTR2 □□ EBER ISH □ Gastric Scoring □□ TNBC (Breast) □□ VEGF BRAF V600E CD99 Glutamine MUC6 (Somatostatin □□ Urothelial Carcinoma Breast CD103 Synthetase MUM1 Receptor, Type 2) Kappa/Lambda ISH PD-L1 SP142 FDA (TECENTRIQ®) Triple Stain CD117 cKIT GLUT1 MyoD1 SOX2 ^ For global HER2 IHC w/results 3+ * Other in 11-49% and/or 2+ is 50% cells, NSCLC (CK5+p63+CK CD117 cKIT Glycophorin A Myogenin SOX10 ≥ □□ (Specify):_________ NeoGenomics will add global HER2 FISH, □□ TNBC (Breast) 8/18) (Melanoma) Glypican-3 Myoglobin SOX11 unless Tech reflex option(s) are marked or □□ Urothelial Carcinoma BRG1 CD123 Granzyme B Napsin A STAT6 “Do Not Reflex” is marked here: □□ PD-L1 28-8 FDA (OPDIVO®)* (SMARCA4) CD138 H3K27me3 NeuN Surfactant __________________ □Do Not Reflex □□ PD-L1 28-8 FDA (OPDIVO® + YERVOY® for NSCLC)* CA19.9 CD163 HBME1 NF (Neurofilament) Synaptophysin *Ordering Pathologist listed has received the required competency training to CA125 CDK4 HCG Beta NGFR TCL1 perform the professional interpretation for this test. Qualitative Calcitonin CDX2 Hemoglobin A NKX2.2 TCR BetaF1 G T G T G T Caldesmon CDX2/CK7 HepPar1 NKX3.1 TCR Delta ALK, D5F3 Gastrin □□ □ □□ □ BRAF V600E □□ □ Calponin Double Stain HGAL NSE TdT (lung, FDA) N/A Pan-TRK (non-heme) □ Calretinin CEA (Mono) HMB45 NUT TFE3 N/A Amyloid A p16 □ □□ □ EGFR (L858R mutant □□ □ CAM 5.2 CEA (Poly) HPL OCT2 Thrombomodulin (TM) N/A Amyloid P ROS1 □ specific) □ □ Carbonic Chromogranin A ICOS OCT4 Thyroglobulin (TGB) N/A Amyloid A&P Panel ZAP70 □ □□ □ EGFR (E746-A750 □□ □ Anhydrase IX CK 5/6 ICOS (non-heme) Olig2 TIA1 (global only)* del specific) (CA IX) CK 7 IDH1 p40 TLE1 *Congo Red slide must accompany sample OR order Consult Carcinoma CK 14 IgA p53 TRAcP Infectious Disease Micromets CK 17 IgD p57 Tryptase G T G T G T (levels with CK 18 IgG p63 TSH □□ □ Adenovirus □□ □ Hep B Surface □□ □ Parvovirus AE1/AE3) CK 19 IgG4 p63 (heme) TTF1 AFB Antigen Periodic Acid □ □ □ □ CD1a CK 20 IgM p120 Catenin Tyrosinase CMV (IHC) HHV8 Schiff for Fungus (PASF) □□ □ □□ □ CD2 CK HMW Inhibin p501S Uroplakin II CMV (ISH) N/A Pneumocystis □ □ □ HPV RNA ISH □□ □ CD3 (CK903/34βBE12) INI1 p504S Uroplakin III EBER ISH (head & neck) Panel (Complete) Carinii (Jiroveci) □□ □ CD4 CK HMW/LMW INSM1 Pan-Cytokeratin Villin N/A EBER ISH (heme) N/A Spirochete □ □ HPV RNA ISH □□ □ CD5 Double Stain Insulin Pan-Cytokeratin Vimentin N/A EBV (LMP1) 16/18 High Risk SV40 □ □ □ CD7 CK OSCAR Kappa/Lambda IHC (sentinel-node) WT1 Fite N/A HPV RNA ISH Toxoplasma □□ □ □ □□ □ CD8 cMyc Ki67 Parafibromin GMS High Risk Cocktail Tuberculosis □□ □ □ □ CD10 Collagen IV Langerin PAX2 Gram Stain □ N/A HPV RNA ISH □□ □ Varicella Zoster CD11c cREL LEF1 PAX5 □ □ Virus (VZV) □□ □ H. Pylori Low Risk Cocktail CD14 CXCL13 LH PAX8 □ □ Hep B Core Antigen □□ □ HSV I/II □□ □ Warthin Starry For our complete test menu, TAT, specimen requirements and more, please visit neogenomics.com Rev.