Therapeutics Requisition Test Request Form · Page 2 of 4 T831 MC0767-19 FeaTURed TeSTING...
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Page 1 of 4 T831 MC0767-19 Therapeutics Test Request Visit www.MayoClinicLaboratories.com for the most up-to-date test and shipping information. Ship specimens to: Mayo Clinic Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 855-516-8404 Billing Information • An itemized invoice will be sent each month. • Payment terms are net 30 days. Call the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US) ©2019 Mayo Foundation for Medical Education and Research Client Information (required) Client Name Client Account No. Client Phone Client Order No. Address City State Zip Code Patient Information (required) Patient ID (Medical Record No.) Patient Name (Last, First, Middle) Gender Male Female Birth Date (Month DD, YYYY) Collection Date (Month DD, YYYY) Time a.m. p.m Patient’s Street Address Phone City State Zip Code MML Internal Use Only Insurance Information (required) Subscriber’s Name (if different than patient) Patient Relationship Spouse Dependent Other ____________________________ Medicare HIC Number (if applicable) Medicaid Number (if applicable) Insurance Company’s Name (if applicable) Insurance Company’s Street Address City State Zip Code Policy Number Group Number “I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on file with this office or the individual’s provider’s office.” Signature __________________________________________________________ Note: It is the client’s responsibility to maintain documentation of the order. Reason for Referral (required) ICD-10 Diagnosis Code Note: It is the client’s responsibility to maintain documentation of the order. New York State Patients: Informed Consent for Genetic Testing Submitting Provider/Provider Name Information (required) Submitting/Referring Provider (Last, First) Fill in only if Call Back is required. Phone ( ) _________ – _________ Fax * ( ) _________ – _________ Provider’s National I.D. (NPI) *Fax number given must be from a fax machine that complies with applicable HIPAA regulation.
Transcript of Therapeutics Requisition Test Request Form · Page 2 of 4 T831 MC0767-19 FeaTURed TeSTING...
Page 1 of 4T831
MC0767-19
Therapeutics Test Request
Visit www.MayoClinicLaboratories.com for the most up-to-date test and shipping information.
Ship specimens to: Mayo Clinic Laboratories 3050 Superior Drive NW Rochester, MN 55901
Customer Service: 855-516-8404
Billing Information • Anitemizedinvoicewillbesenteachmonth. • Paymenttermsarenet30days.
Call the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US)
©2019 Mayo Foundation for Medical Education and Research
Client Information (required)
Client Name
ClientAccountNo.
Client Phone Client Order No.
Address
City State Zip Code
Patient Information (required)
Patient ID (Medical Record No.)
Patient Name (Last, First, Middle)
Gender Male Female
Birth Date (Month DD, YYYY)
Collection Date (Month DD, YYYY) Time a.m. p.m
Patient’sStreetAddress
Phone
City State Zip Code
MML Internal Use Only
Insurance Information (required)
Subscriber’s Name (if different than patient)
Patient Relationship Spouse Dependent Other ____________________________
Medicare HIC Number (if applicable)
Medicaid Number (if applicable)
Insurance Company’s Name (if applicable)
InsuranceCompany’sStreetAddress
City State Zip Code
Policy Number
Group Number
“I hereby confirm that informed consent has been signed by an individual legally authorizedtodosoandisonfilewiththisofficeortheindividual’sprovider’soffice.”
Signature __________________________________________________________
Note: It is the client’s responsibility to maintain documentation of the order.
Reason for Referral (required)
ICD-10 Diagnosis Code
Note: It is the client’s responsibility to maintain documentation of the order. New York State Patients: Informed Consent for Genetic Testing
Submitting Provider/Provider Name Information (required)
Submitting/Referring Provider (Last, First)
Fill in only if Call Back is required.Phone ( ) _________ – _________Fax * ( ) _________ – _________
Provider’s National I.D. (NPI)
*Fax number given must be from a fax machine that complies with applicable HIPAA regulation.
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FeaTURed TeSTING
Controlled Substance Monitoring Panels
CSMP Controlled Substance Monitoring Panel, Random, Urine
TOSU Targeted Opioid Screen, Random, Urine
TBSU TargetedBenzodiazepineScreen,Random, Urine
Pharmacogenomics Panels PGXFP Focused Pharmacogenomics Panel,
Varies
PSYGP Psychotropic Pharmacogenomics Gene Panel, Varies
CONTROLLed SUBSTaNCe MONITORING
Panels
CDAU5 DrugAbuseSurveywithConfirmation,Panel 5, Random, Urine
CDAU7 DrugAbuseSurveywithConfirmation,Panel 9, Random, Urine
CDAU DrugAbuseSurveywithConfirmation,Random, Urine
CSMP Controlled Substance Monitoring Panel,Random, Urine
TOSU Targeted Opioid Screen, Random, Urine
TBSU TargetedBenzodiazepineScreen,Random, Urine
VLTS Volatile Screen, Serum
VLTU Volatile Screen, Random, Urine
adulterants ADULT AdulterantsSurvey,Random,Urine
amphetamines AMPHU AmphetaminesConfirmation,
Random, Urine
Barbiturates BARBU Barbiturates Confirmation,
Random, Urine
Benzodiazepines BENZU BenzodiazepinesConfirmation,
Random, Urine
Buprenorphine BUPM Buprenorphine and Norbuprenorphine,
Random, Urine
BUPS Buprenorphine Screen, Random, Urine
BUPR Buprenorphine Screen with Reflex, Random, Urine
Cocaine COKEU Cocaine and Metabolite Confirmation,
Random, Urine
ethanol & ethanol Metabolites ALC Ethanol, Blood
ETOH Ethanol, Random, Urine
ETGC Ethyl Glucuronide Confirmation, Random, Urine
ETGS Ethyl Glucuronide Screen, Random, Urine
ETGR Ethyl Glucuronide Screen with Reflex,Random, Urine
Heroin Metabolites 6MAMU 6-Monoacetylmorphine Confirmation,
Random, Urine
LSd and PCP LSDU LysergicAcidDiethylamide(LSD)
Confirmation, Random, Urine
PCPU Phencyclidine Confirmation, Random, Urine
Opioids FENS Fentanyl Screen, Random, Urine
FENR Fentanyl Screen with Reflex, Random, Urine
FENTU Fentanyl with Metabolite Confirmation,Random, Urine
HYDCU Hydrocodone with MetaboliteConfirmation, Random, Urine
HYDMU Hydromorphone Confirmation, Random, Urine
MTDNU Methadone Confirmation, Random, Urine
OPATU Opiates Confirmation, Random, Urine
OXYSU Oxycodone Screen, Random, Urine
OXYCU Oxycodone with Metabolite Confirmation,Random, Urine
OXYMU Oxymorphone Confirmation, Random, Urine
TAPEN Tapentadol and Metabolite, Random,Urine
TRAM Tramadol and Metabolite, Random, Urine
Other KETAU Ketamine and Metabolite Confirmation,
Random, Urine
Tobacco Products NICOS Nicotine and Metabolites, Serum
NICOU Nicotine and Metabolites, Random, Urine
NCSRY Nicotine Survey, Serum
THC THCU Carboxy-Tetrahydrocannabinol (THC)
Confirmation, Random, Urine
Serum Testing BUTAS Butalbital, Serum
CZPS Clonazepamand7-Aminoclonazepam,Serum
PENTS Pentobarbital, Serum
PBR Phenobarbital, Serum
ETHNL Ethanol, Serum
DIA DiazepamandNordiazepam,Serum
SECOS Secobarbital, Serum
CDTA Carbohydrate Deficient Transferrin, Adult,Serum
FENTS Fentanyl, Serum
MDNS Methadone and Metabolites, Serum
CDP ChlordiazepoxideandMetabolite,Serum
DIA DiazepamandNordiazepam,Serum
Chain of Custody ADLTX AdulterantsSurvey,ChainofCustody,
Random, Urine
CDAUX DrugAbusePanelwithConfirmation,Chain of Custody, Random, Urine
CDA5X DrugAbuseSurveywithConfirmation,Panel 5, Chain of Custody, Random, Urine
CDA7X DrugAbuseSurveywithConfirmation,Panel 9, Chain of Custody, Random, Urine
DSSX Drug Screen, Prescription/OTC, Chain of Custody, Serum
PDSUX Drug Screen, Prescription/OTC, Chain ofCustody, Random, Urine
PANOX Pain Clinic Survey 10, Chain of Custody,Random, Urine
VLTUX Volatile Screen, Chain of Custody, Random, Urine
6MAMX 6-Monoacetylmorphine Confirmation, Random, Urine
AMPHX AmphetaminesConfirmation,Chain of Custody, Random, Urine
BARBX Barbiturates Confirmation, Chain of Custody, Random, Urine
BENZX BenzodiazepinesConfirmation,Chain of Custody, Random, Urine
BUPMX Buprenorphine and Norbuprenorphine,Chain of Custody, Random, Urine
COKEX Cocaine and Metabolite Confirmation,Chain of Custody, Random, Urine
ALCX Ethanol, Chain of Custody, Blood
ETOHX Ethanol, Chain of Custody, Random, Urine
ETGX Ethyl Glucuronide Confirmation, Chain of Custody, Random, Urine
Patient Information (required)
Patient ID (Medical Record No.) ClientAccountNo.
Patient Name (Last, First, Middle) Client Order No.
Birth Date (Month DD, YYYY)
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PCPX Phencyclidine Confirmation, Chain of Custody, Random, Urine
FNTSX Fentanyl and Metabolite, Chain of Custody, Serum
FENTX Fentanyl with Metabolite Confirmation,Chain of Custody, Random, Urine
MTDNX Methadone Confirmation, Chain ofCustody, Random, Urine
OPATX Opiates Confirmation, Chain of Custody,Random, Urine
OXYSX Oxycodone Screen, Chain of Custody,Random, Urine
OXYCX Oxycodone with Metabolite Confirmation,Chain of Custody, Random, Urine
THCX Carboxy-Tetrahydrocannabinol (THC)Confirmation, Chain of Custody, Random, Urine
NeONaTaL exPOSURe
Meconium Testing OPATM Opiate Confirmation, Meconium
THCM 11-nor-Delta-9-Tetrahydrocannabinol-9-CarboxylicAcid(Carboxy-THC)Confirmation, Meconium
DASM4 DrugsofAbuseScreen,Meconium4
DASM5 DrugsofAbuseScreen,Meconium5
6MAMM 6-Monoacetylmorphine(6-MAM),Confirmation, Meconium
COKEM Cocaine and Metabolites Confirmation, Meconium
PCPMC Phencyclidine (PCP) Confirmation, Meconium
Meconium Chain of Custody DSM4X DrugsofAbuseScreen4,Chainof
Custody, Meconium
DSM5X DrugsofAbuseScreen5,ChainofCustody, Meconium
MAMMX 6-Monoacetylmorphine(6-MAM)Confirmation, Chain of Custody, Meconium
AMPMX Amphetamine-TypeStimulantsConfirmation, Chain of Custody, Meconium
COKMX Cocaine and Metabolite Confirmation, Chain of Custody, Meconium
PCPMX Phencyclidine (PCP) Confirmation, Chain of Custody, Meconium
OPTMX Opiate Confirmation, Chain of Custody, Meconium
THCMX 11-nor-Delta-9-Tetrahydrocannabinol-9-CarboxylicAcid(Carboxy-THC)Confirmation, Chain of Custody, Meconium
PHaRMaCOGeNOMICS
General Panels PGXFP Focused Pharmacogenomics Panel,
Varies
PSYGP Psychotropic Pharmacogenomics Gene Panel, Varies
Targeted Panels CARPB CarbamazepineHypersensitivity
Pharmacogenomics, Blood
CARPO CarbamazepineHypersensitivityPharmacogenomics, Saliva
TPNUV Thiopurine Methyltransferase (TPMT) and Nudix Hydrolase (NUDT15) Genotyping, Varies
WARSV Warfarin Response Genotype, Varies
Single Gene Tests COMTV Catechol-O-Methyltransferase (COMT)
Genotype, Varies
1A2V CytochromeP4501A2Genotype,Varies
2B6V Cytochrome P450 2B6 Genotype, Varies
2C19V Cytochrome P450 2C19 Genotype, Varies
2C9GV Cytochrome P450 2C9 Genotype, Varies
2D6CV Cytochrome P450 2D6 (CYP2D6) Comprehensive Cascade, Varies
3A4V CytochromeP4503A4Genotype,Varies
3A5V CYP3A5Genotype,Varies
DPYDG Dihydropyrimidine Dehydrogenase,DPYD Full Gene Sequencing, Varies
DPYDV Dihydropyrimidine DehydrogenaseGenotype, Varies
G6PDB Glucose-6-Phosphate Dehydrogenase(G6PD) Full Gene Sequencing, Varies
HL57V HLA-B*57:01Genotype,Pharmacogenomics, Varies
HLA58 HLA-B*5801Genotype,AllopurinolHypersensitivity, Blood
HL58O HLA-B*5801Genotype,AllopurinolHypersensitivity, Saliva
IL28V Interleukin 28B (IL28B) Variant (rs12979860), Varies
NAT2 N-Acetyltransferase2Gene(NAT2),Full Gene Sequence, Whole Blood
NAT2O N-Acetyltransferase2Gene(NAT2),Full Gene Sequence, Saliva
SLC1V SoluteCarrierOrganicAnionTransporterFamily Member 1B1 (SLCO1B1) Genotype, Statin, Varies
U1A1V UDP-GlucuronosylTransferase1A1TARepeatGenotype,UGT1A1,Varies
UGTFG UDP-GlucuronosylTransferase1A1(UGT1A1),FullGeneSequencing,Varies
THeRaPeUTIC dRUG MONITORING
antiarrhythmics AMIO Amiodarone,Serum
FRDIG Digoxin, Free, Serum
DIG Digoxin, Serum
FLEC Flecainide, Serum
LID Lidocaine, Serum
MEX Mexiletine, Serum
PA Procainamide and N-acetylprocainamide, Serum
PFN Propafenone, Serum
QUIN Quinidine, Serum
antibiotics PAMIK Amikacin,Peak,Serum
RAMIK Amikacin,Random,Serum
TAMIK Amikacin,Trough,Serum
GENPA Gentamicin, Peak, Serum
GENRA Gentamicin, Random, Serum
GENTA Gentamicin, Trough, Serum
PLAZO Plazomicin,Plasma
SFZ Sulfamethoxazole,Serum
TOBPA Tobramycin, Peak, Serum
TOBRA Tobramycin, Random, Serum
TOBTA Tobramycin, Trough, Serum
VANPA Vancomycin, Peak, Serum
VANRA Vancomycin, Random, Serum
VANTA Vancomycin, Trough, Serum
Patient Information (required)
Patient ID (Medical Record No.) ClientAccountNo.
Patient Name (Last, First, Middle) Client Order No.
Birth Date (Month DD, YYYY)
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anticonvulsants CARBG Carbamazepine-10,11-Epoxide,Serum
CARFT Carbamazepine,FreeandTotal,Serum
CARF Carbamazepine,Free,Serum
CARTF CarbamazepineProfile,Serum
CARTA Carbamazepine,Total,Serum
CLOBZ ClobazamandMetabolite,Serum
CZPS Clonazepamand7-Aminoclonazepam,Serum
ETX Ethosuximide, Serum
FELBA Felbamate (Felbatol), Serum
GABA Gabapentin, Serum
LAMO Lamotrigine, Serum
LEFLU Leflunomide Metabolite (Teriflunomide), Serum
LEVE Levetiracetam, Serum
MEPHS Mephobarbital and Phenobarbital, Serum
OMHC OxcarbazepineMetabolite(MHC),Serum
PENTS Pentobarbital, Serum
PBR Phenobarbital, Serum
PNYF Phenytoin, Free, Serum
PNTFT Phenytoin, Total and Free, Serum
PNYG Phenytoin, Total and Phenobarbital Group, Serum
PNYA Phenytoin, Total, Serum
PGN Pregabalin, Serum
PRMB Primidone and Phenobarbital, Serum
RUFI Rufinamide, Serum
TOPI Topiramate, Serum
TMP Trimethoprim, Serum
VALPG ValproicAcid,FreeandTotal,Serum
VALPF ValproicAcid,Free,Serum
VALPA ValproicAcid,Total,Serum
ZONI Zonisamide, Serum
antidepressants AMTRP AmitriptylineandNortriptyline,Serum
CITAL Citalopram, Serum
CLOM Clomipramine, Serum
DESPR Desipramine, Serum
DXPIN Doxepin and Nordoxepin, Serum
DULOX Duloxetine, Serum
FLUOX Fluoxetine, Serum
IMIPR Imipramine and Desipramine, Serum
NOTRP Nortriptyline, Serum
PARO Paroxetine, Serum
TRMP Trimipramine, Serum
VENLA Venlafaxine, Serum
antifungals
FLUC 5-Flucytosine, Serum
ITCON Itraconazole,Serum
POSA Posaconazole,Serum
antineoplastic agents
BUAUC Busulfan,IntravenousDose,AreaUndertheCurve(AUC),Plasma
MTHX Methotrexate, Serum
antipsychotics CLZ Clozapine,Serum
HALO Haloperidol, Serum
LITH Lithium, Serum
antivirals GANC Ganciclovir, Serum
RIBAV Ribavirin, Serum
Bronchodilators THEO Theophylline, Serum
Immunosuppressants CYSPR Cyclosporine, Blood
CYCPK Cyclosporine, Peak, Blood
EVROL Everolimus, Blood
HCQ Hydroxychloroquine, Serum
MPA MycophenolicAcid,Serum
SIIRO Sirolimus, Whole Blood
TAKRO Tacrolimus, Blood
TACPK Tacrolimus, Peak, Blood
Stimulants CAFF Caffeine, Serum
TOxICOLOGY
emergency/Overdose
ETGL Ethylene Glycol, Serum
DSS Drug Screen, Prescription/OTC, Serum
PDSU Drug Screen, Prescription/OTC, Random, Urine
COHBB Carbon Monoxide, Blood
HYPOG HypoglycemicAgentScreen,Serum
MTXSG Methotrexate Post Glucarpidase, Serum
ACMA Acetaminophen,Serum
SALCA Salicylate, Serum
addITIONaL TeSTS (INdICaTe TeST COde aNd NaMe)
Patient Information (required)
Patient ID (Medical Record No.) ClientAccountNo.
Patient Name (Last, First, Middle) Client Order No.
Birth Date (Month DD, YYYY)
