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MORPHOLOGY I

FLOW CYTOMETRY

I LymphoidI ZAP-70I Myeloid/Lymphoid and Acute Leukemia

I PNH (including FLAER) (Peripheral Blood Only)I Multiple Myeloma

CYTOGENETICS

I Cytogenetics KaryotypingI Cytogenetics w/ reflex to FISH as necessary

FISH

PANELS: I ALCL* I ALL I AML I B-ALL I T-ALLI BM Transplant MonitoringI

CLLI

CML (BCR-ABL/ASS)I

CML Blast CrisisI MDS I MM I MM Purified Plasma CellI MPD I NHL

OTHER _______________________________________________________*ANAPLASTIC LARGE CELL LYMPHOMA

MOLECULAR PATHOLOGY

Acute Myeloid Leukemia (AML)

I c-KIT Mutation (Exon 8 and 17)I CEBPA MutationI FLT3 Mutation (ITD, D835)I NPM1 Mutation (Exon 12)

Chronic Lymphocytic

Leukemia/Small Lymphocytic

Leukemia (CLL/SLL)

I IGHV MutationI MatBA-CLL/SLL Array CGHI NOTCH1 MutationI TP53 MutationI SF3B1 Mutation

Lymphoma

I T-Cell Clonality (TCR)I T-Cell Clonality (TCR)I B-Cell Clonality (IGH)I MatBA-DLBCL Array CGHNon-CML Myeloproliferative

Neoplasms (MPN)

I c-KIT Mutation(Mast Cell Disease) (D816)

I JAK2 V617 Mutation with Reflex toI MPL 515/505 Mutation (MPN)I JAK2 Exon 12 Mutation (MPN)

I JAK2 Exon 12 MutationI MPL 515/505 Mutation

PATIENT INFORMATION

Name (Last, First, Middle Initial)

Address

Sex I Male I Female D.O.B.

Social Security # Phone

( )

Med. Rec. No. / Patient No. / Specimen No.

Bill: I Insurance I Medicare Part B I Patient I Hospital / InstitutionPatient Status: I Inpatient I Outpatient I Non-Hospital patientPre-Authorization #

Medicare # I See Attached Billing Info

Healthplan I See Attached Billing Info

Address

Policy / Cert. # Group / Plan #

Medical Group

Secondary Insurance I Yes I No (If Yes, Please Attach)

I Peripheral Blood ___Green Top ___Purple Top I Other________________I Bone Marrow ___Green Top ___Purple TopI Core Biopsy ___Clot ___Other_____________________

I Smears: ___Air Dried ___Fixed___Stained ___Type of Stain

I Tissue Body Site_______________________________________FFPE ___Block ____Slides ____Fresh ____Frozen

Other______________________________________________________________

Collection Date_________________________ Collection Time_________________________

Diagnosis or Signs/Symptoms (ICD-9 or Narrative, see reverse side for ICD-9 codes):

______________________________________________________________________

_____________________________________________________________________

I Acute Leukemia I AML I APL I ALLI Anemia I Pancytopenia I Other _______________________________________I Lymphoproliferative DisordersI CLL/SLL I Burkitts lymphoma I DLBCL I FL I HCLI Hodgkins lymphomaI Marginal zone lymphoma I MCL I T/NK cell lymphoma I Other ___________

I MDSI MM/MGUS/Plasma Cell Neo I Other ____________________________________I Myeloproliferative NeoplasmsI CML I PV I ET I PMF I Other ___________________________________

TREATMENT STATUS

I New Diagnosis I Follow Up I MRD I Relapse I Monitoring I Remission

THERAPY

I Current Type: _______________________________________________________I Prior (>1 month ago) I Rituxan I Campath I GleevecI Mylotarg I VelcadeI Chemotherapy I Radiotherapy I EPO I GCSF I GMCSFI Other _______________________________________________________________Bone Marrow Transplant: Type: I Autologous I Allogeneic I Sex Mismatch

CLIENT INFORMATION

Client

Address

Ordering Physician NPI #

Phone Fax

( ) ( )

201 Route 17 North, 2nd Floor Rutherford, NJ 07070

Phone: 201-528-9187 Fax: 201-933-0787 Toll Free: 888-334-4988 www.cancergenetics.com

Based on the diagnosis under consideration, CGI will perform a comprehensivepanel evaluation including bone marrow/blood morphology, flow cytometry,cytogenetics and/or FISH and molecular studies as determined necessary by aCGI Hematopathologist and Technical Directors.

I SUMMATION BLOOD EVALUATION:____________________________I SUMMATION BONE MARROW EVALUATION: ____________________I CLL COMPLETESM EVALUATION I DLBCL COMPLETESM EVALUATION(SEE MENU ON BACK, FOR REFERENCE ONLY)

PHYSICIAN SIGNATURE ___________________________________

INDIVIDUAL STUDIES

CLINICAL INFORMATION

COMPREHENSIVE EVALUATIONS

BILLING INFORMATION (ATTACH FACE SHEET AND A COPY OF FRONT AND BACK OF INSURANCE CARD)

LAB USE ONLY

Accession # ___________________________

Date:______________ Time:______________

HEMATOLOGY/ONCOLOGY

SPECIMEN INFORMATION

Chronic Myeloid Leukemia (CML)

I ABL Kinase Domain MutationI Qualitative BCR-ABL (PCR) (For new diagnosis ONLY)I Quantitative BCR-ABL (PCR) (For follow up, MRD ONLY)I Major (p210) (IS)I Minor (p190)

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I 204.0 Acute Lymphoid LeukemiaI 205.1 Chronic Eosinophilic LeukemiaI 245.2 Chronic Lymphocytic ThyroiditisI 204.1 Chronic Lymphoid LeukemiaI 288.5 Decreased white blood cell countI 785.6 Enlargement of lymph nodesI 289.6 ErythrocytosisI 238.71 Essential Thrombocythemia (ET)I 191.90 Glioblastoma, unspecified siteI 245.2 Hashimoto's DiseaseI 287.31 Immune thrombocytopenic

purpura (ITP)

I 202.40 Hairy Cell, LeukemicI 288.50 Leukocytopenia, unspecifiedI 288.51 LymphocytopeniaI 288.61 Lymphocytosis (symptomatic)I 273.1 Monoclonal Gammapthy /

Monoclonal

paraproteinemia (MGUS)I 203.0 Multiple MyelomaI 238.75 Myelodysplastic Syndrome,

unspecified (MDS)

I 238.76 Myelofibrosis with MyeloidMetaplasia

I 238.79 Myeloproliferative Disease (MPD)I 201.9 Non Hodgkins Disease,

unspecified

I 202.8 Other LymphomasI 284.1 PancytopeniaI 203.1 Plasma cell leukemiaI 238.6 Plasma cellsI 238.40 Polycythemia vera (PV)I 135.00 SarcoidosisI 287.5 Thrombocytopenia, unspecifiedI 435.9 Transient Ischemic attack (TIA)/

Unspecified transient cerebralischemia

I 205.9 Unspecified Myeloid LeukemiaI 285.9 AnemiaI 280.9 Anemia, microcyticI 281.9 Anemia, macrocyticI 288.0 NeutropeniaI 288.00 Neutropenia, unspecifiedI 288.2 Neutrophilia

I 288.3 EosinophiliaI 288.63 Monocytois (symptomatic)I 288.65 BasophiliaI 273.2 ParaproteinemiaI 202.0 Lymphoma, FollicularI 202.8 Lymphoma, Large B CellI 200.2 Lymphoma, BurkittsI 200.4 Lymphoma, Mantle cellI 202.1 Lymphoma, T-CellI 200.6 Lymphoma, Large cell anaplasticI 202.8 Non-Hodgkins LymphomaI 200.7 Large Cell LymphomaI 273.3 Waldenstroms SyndromeI 273.0 Waldenstroms purpura,

hypergammaglobulinemia

I 202.1 Mycosis, mycotic fungoidesI 117.9 Mycosis, mycoticI 202.2 Sezarys Syndrome

ICD-9:_______________________________

ICD-9 codes are listed as a convenience. Ordering physicians should report the code that best describes the reason for ordering the test and are not required to use the codes provided.

ICD-9 CODES

FISH: PROBES AND PANELS

HEMATOLOGIC MALIGNANCIES

Acute Lymphocytic Leukemia (ALL)B-ALL PEDIATRIC/ADULT

! 11q23 (MLL-Break Apart)! t(9;22) (BCR/ABL/ASS)! 17p13 (TP53)! t(12;21) (ETV6/RUNX1)!

9p21 (p16/CDKN2A)! CEP4, 10, 17Acute Lymphocytic Leukemia (ALL)T-ALL

! 14q11 (TCR-Alfa/Delta Break Apart)Acute Myeloid Leukemia (AML)

! t(8;21) (ETO/AML1) [M2]! t(15;17) (PML/RARA) [M3]! inv(16) (CBFB-Break Apart) [M4, Eos]! 11q23 (MLL-Break Apart)

Anaplastic Large Cell Lymphoma (ALCL)

! 2p23 (ALK-Break Apart)BM Transplant Monitoring

! CEP X/Y

Chronic Lymphocytic Leukemia (CLL)

! 11q22.3 (ATM)/17p13 (TP53)! CEP12/13q14 (D13S319)/13q34! CEP6/6q23 (c-MYB)! t(11;14) (CCND1/IGH)

Chronic Myelogenous Leukemia (CML)

! t(9;22) (BCR/ABL/ASS)CML in blast crisis

! t(9;22) (BCR/ABL/ASS)! 17p13 (TP53)! CEP8

Multiple Myeloma (MM) with purifiedplasma cells (PPC)

! 13q14/13q34! 17p13 (TP53)!

1p/1q! D5S23/D5S72/CEP9/CEP15! t(4;14) (FGFR3/IGH)! t(11;14) (CCND1/IGH)! t(14;16) (lGH/MAF)

D3/IGH)t(14;20) (IGH/MAF

Myelodysplastic Syndrome (MDS)

! 5p15.2/5q31! CEP7/7q31! CEP8! 20q12! 11q23 (MLL-Break Apart)

Myeloproliferative Disease (MPD)

! 4q12 (FIP1L1/CHIC2/PDGFRA)! 5q33 (PDGFRB-Break Apart)! BCR/ABL (BCR/ABL/ASS)! CEP8/CEP9

Non-Hodgkins Lymphoma (NHL)

Burkitt - t(8;14) (MYC/IGH)

DLBCL - 3q27 (BCL6-Break Apart)Follicular - t(14;18) (IGH/BCL2)

Mantle - t(11;14)(CCND1/IGH)MALT Lymphoma - MALT1-Break Apart

Also Available! IGH-Break Apart! c-MYC-Break Apart

CEP X/Y

SOLID TUMORS

! ALK-Break Apart (NSCLC) [FDA approved]! PathVysion (HER2/neu) (Breast) [FDA approved]! UroVysion (Bladder) [FDA approved]

Also available! IGH-Break Apart! CEP7/CEP11! t(6;14) (CCND3/IGH)! t(14;20) (IGH/MAFB)available

C

Chronic LMOLECULMatBA-CLLIGHV MutatiTP53 MutatioNOTCH1 MuSF3B1 Mutat

FLOW CYTZAP-70; CD3

MPLETE

ymphocytic LR PATHOLO

SLLn Analysisn Analysistation Analysision Analysis

OMETRY8

PROGRAMS

eukemia (CLY KARYOTY

FISH11q22.3 (ATCEP12/13q1CEP6/6q23t(11;14) (CC

)PING

M)/17p13 (TP53)4 (D13S319)/13q(c-MYB)ND1/IGH)

Diffuse

34

MOLECUMatBA-DL6 Gene Ex Assay

TP53 MutatB-Cell Clon

FLOW CY

GCB vs. N

arge B-Cell LAR PATHOLO

BCLression Outcome

ion AnalysisalityTOMETRY

n-GCB Subtypin

ymphoma (DGY KARYO

FISH3q27 (BT(8;14) (T(14;18)

IHC

CD3, CD

BCL)TYPING

L6-Break Apart)MYC/IGH)(IGH/BCL2)

5, CD10, CD20, D45