Fillable Add-On Test Authorization Patients insurance information required for

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Add-On Test Authorization Patients insurance information required for

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_______________________________________________________________________________________________
REQUIRED - Physician or authorized designee signature
_______________________________________________________________________________________________
PRINT NAME
For CellNetix Use Only-
051221
Date Received: SSS Initials:
Pathologist Initials:
SymGene Focus - Targeted NGS Cancer Panels:
Breast Panel (8 genes including: PIK3CA, BRCA1/2 and ESR1)
Colon Panel (10 genes including: KRAS, NRAS, BRAF, MMR genes)
GIST Panel (KIT, PDGFRa and BRAF)
Lung Panel (13 genes including: EGFR, BRAF, MET + ALK/ROS1 FISH + PD-L1 IHC for Keytruda)
Melanoma Panel (7 genes including BRAF, NRAS, KIT, CTNNB1, GNAQ, GNA11, GNAS)
Ovarian Panel (18 genes including: BRCA1/2, TP53, CTNNB1, MMR genes)
Next Generation Sequencing (NGS)
SymGene: 79 Gene Cancer Panel (NGS--V1.5 for solid tumors, ALK/ROS1 FISH included)
Pap only
Pap+HPV
Pap+HPV+Genotype (if positive)
HPV
HPV+Genotype (if positive)
Anal HPV
GC/CT
Trich
BV/CV
HSV
(NGS) Colon Panel: See Below
KRAS BRAF NRAS
KRAS
BRAF
NRAS
MMR-IHC (Mismatch Repair)
MSI (Microsatellite Instability)
MLH1 Promoter Methylation
HER2 Gastric/Esophageal
(NGS) Lung Panel: See Below
EGFR+ALK/ROS1+PD-L1 (Keytruda)
EGFR
BRAF
ALK gene rearrangement
ROS1 gene rearrangement
EGFR+ALK
EGFR+ALK/ROS1
EGFR reflexed to ALK/ROS1
EGFR_T790M mutation only
PD-L1 (IHC) for Keytruda
PD-L1 (IHC) for Opdivo
PD-L1 (IHC) for Tecentriq
(NGS) Breast Panel: See Below
PIK3CA
Breast Panel HER2 IHC, ER/PR, Ki67,
Reflex to HER2 FISH if equivocal
HER2 IHC
HER2 FISH
ER IHC
PR IHC
ER/PR IHC
Ki67 IHC
PD-L1 (IHC) for Tecentriq
MSI-PCR_Keytruda
MMR-IHC_Keytruda
Other:________________________________________________________________________________________________
(NGS) Melanoma Panel: See Below
BRAF
NRAS
KIT
(NGS) Ovarian Panel: See Below
MMR-IHC (Mismatch Repair)
MLH1 Promoter Methylation
Cytology
GI
Lung (NSCLC)
Breast
For OncotypeDX, Contact
Genomic Health: 866-662-6897
NonGyn
Any Solid Tumor
Derm
Gyn
Keytruda
Opdivo
Tecentriq
PD-L1 Other
Liposarcoma
MDM2 FISH
(NGS) GIST Panel: See Below
KIT
PDGFRa
Afirma GSC/XA
Reflex Afirma XA if SM/M
ThyroSeq
ThyGeNEXT/ThyraMIR
Urovysion - Urine
Urovysion - Pancreatic brushing
Patient’s Name:__________________________________ CellNetix Accession #/Consult Accessions:______________________
Patient’s Date of Birth:_____________________________ Original CellNetix Date of Service:_____________________________
ICD10:__________________________________________________Ordering Physician and Facility:______________________
Patient’s insurance information required for add-on testing.
PLEASE PRINT CLEARLY
Date of Request:__________________________________
Fax: 206-215-5935 or 866-721-9696
Add-On Test Authorization
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Completed 10 August 2021

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