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IHC Requisition INSURANCE / BILLING INFORMATION - REQUIRED:

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Last Name First Name Middle Initial
Address City State ZIP
DOB Age Gender SSN Phone
Ordering Physician MRN
Treating Physician Specimen ID
Original and Second Copy (White / Canary) - CSI Laboratories
PAC008- 0
1/09/19
Bottom Copy (Pink) - Client
2580 Westside Parkway, Alpharetta, GA 30004
PH 1-800-459-1185 FAX 1-888-809-9071
INSURER POLICY # GROUP #
INSURER POLICY # GROUP #
IHC Requisition
CLIENT IDENTIFICATION
BILLING INFORMATION
SPECIMEN INFORMATION
INSURANCE INFORMATION Attached face sheet/insurance Self Spouse Child Other
PATIENT IDENTIFICATION
Date Packaged / /
Collection Date Time
Date of Discharge ABN is available
Date Pulled from Archive
Bill to:
Client Insurance Patient
Hospital status when specimen collected:
Hospital Inpatient Hospital Outpatient Non-Hospital Outreach/Clinic Patient
Additional Tests, Comments, or Differential Diagnosis
Medicare # Medicaid # Pre-Authorization #
Primary Ins. Secondary Ins.
M / F
Two unique identifiers are required on requisition & specimen
ICD-10 Code(s):
(ICD-10 information is required)
Authorized Signature
CSI Laboratories Use Only
LABORATORY TEST REQUESTED
A-1-ACT
A-1-AT
ACTH
Adenovirus
AE1
AE1/AE3
AFP
ALK-1 (5A4)
Amyloid A
Annexin 1
AR (Androgen Rec.)
Arginase-1
B72.3 (TAG72)
BCL-1 (Cyclin D1)
BCL-2
BCL-6
Ber-EP4
Beta-Catenin
BG8 (Lewis Y)
CAIX
CA 125
CA 19.9
Calcitonin
Caldesmon
Calponin
Calretinin
CAM 5.2
CD10 (CALLA)
CD117 (c-KIT)
CD11c
CD123
CD138
CD15 (LeuM1)
CD163
CD19
CD1a
CD2
CD20 (L26)
CD21
CD22
Body Site
Formalin Fixed Other Fixation
Cold Ischemia Time
(min) Fixation Time (hours)
Block(s) # Slide(s) # Other #
CD23
CD25
CD3
CD30 (Ber-H2)
CD31
CD33
CD34
CD38
CD4
CD43
CD44
CD
45 (LCA)
CD45RO (UCHL-1)
CD5
CD56 (NCAM)
CD57
CD61
CD68
CD7
CD71
CD79a
CD8
CD99
CDK4 by IHC
CDX2
CEA (m)
CEA (p)
Chromogranin A (m)
Chromogranin A (p)
Chymotrypsin
CMV
c-MYC
CK14
CK17
CK19
CK20
CK5/6
CK7
CK8
CK8/18
CK903
D2-40 (Podoplanin)
DBA-44
Desmin
DOG-1
E-cadherin
EBER by ISH
EBV LMP
EGFR by IHC
EMA
Epi/Myoepithelial Cktl (EMEC)
(CK5+CK14+p63; Red CK8/18)
ER
Factor VIII
Factor XIIIa
Fascin
Fli-1
FOXp3
FSH
Galectin-3
Gastrin
GATA-3
GCDFP-15
GFAP
GH
Glucagon
Glycophorin A (CD235)
Glypican-3
Granzyme B
H. Pylori
HBcAg (Hepatitis B Core Antigen)
HBME-1
HBsAg
HCG
Hemoglobin A
Hepatocyte (HepPar -1)
HER2 by IHC
HHV-8
HLA-DR
HMB-45
hMLH-1
hMSH-2
hMSH-6
hPL
HSV I/II
IgA
IgD
IgE
IgG (p)
IgG4(m) + IgG(p)
IgM
Inhibin
INI-1
Insulin
Kappa by IHC
Kappa/Lambda Double Stain
Kappa by ISH
Ki-67
Ki-67 + CD138 Double Stain
Lambda by IHC
Lambda by ISH
LH
Lysozyme (Muramidase)
Mammaglobin
MART-1
MDM2 by IHC
Melan-A
Mesothelin
Micrometastases (CK8/18)
MOC-31
MPO
MSA (Muscle Specific Actin)
MUC1
MUC2
MUC4
MUC5AC
MUC6
MUM-1
MyoD1
Myogenin
Napsin A
NF
NSE
NY-BR-1
OCT-2
OCT-3/4
p120
p16 (CINtec)
p21 (WAF1)
p27
p40
p504S (AMACR)
p53
p57
p63
Pan-Melanoma
(HMB45/Melan-A/Tyrosinase)
Parvovirus B19
PAX-2
PAX-5
PAX-8
PCP (Pneumocystis)
PD-1
PD-L1 (Avail. Only as Global)
PHH3
Prostate Triple Stain
(CK903+p63; Red p504S)
PLAP
PMS2
PP (Pancreatic Polypeptide)
PR
Prolactin
PSA
PSAP
PTH
RCC (PNRA)
S100
S100p
SALL4
SATB2
REQUESTED TESTING
LEVEL OF SERVICE:
Global (with interpretation)
Slide Only (TC): glass slides only
Web-Enabled (TC): digital images through e.CSI™
Serotonin
SMM-HC
SMA
Somatostatin
SOX-10
SOX-11
Surfactant Apoprotein A
Synaptophysin
TdT
Thrombomodulin
Thyroglobulin
TIA-1
Toxoplasma Gondii
TRAcP
Treponema Pallidum
Trypsin
Tryptase (Mast Cell)
TSH
TTF-1
Tyrosinase
Uroplakin II
Villin
Vimentin
VIP
VZV (Varicella Zoster)
WT-1 (N-terminus)
ZAP-70
IMAGE ANALYSIS
ER
PR HER2 Ki-67 p53
ADD’L TESTING (Global)
HER2 FISH
TOP2A FISH
DNA Ploidy by Flow
TFE3 by FISH
HER2/D17S122 by FISH
MDM2 by FISH
SS18 by FISH
Physician Notice: Only tests or diagnostic services that are medically necessary should be ordered. Appropriate ICD-10 information must be provided in the specified area above.
Payors, including Medicare and Medicaid, generally do not pay for screening tests.
2580 Westside Parkway, Alpharetta, GA 30004
P: 1-800-459-1185 | F: 1-888-809-9071
Date packaged:
IHC Requisition
CSI_09192021
CLIENT IDENTIFICATION PATIENT IDENTIFICATION
INSURANCE / BILLING INFORMATION - REQUIRED: Please include face sheet and front/back of paent’s insurance card.
SPECIMEN INFORMATION (Two unique ideners are required on requision & specimen) *
ADDITIONAL TESTS, COMMENTS OR DIFFERENTIAL DIAGNOSIS PROGNOSTIC
Image Analysis Global Image Analysis Technical Slide Only
ER PR HER2 Ki-67 p53
For global HER2 IHC with results 2+, CSI will add HER2 FISH unless marked
Do Not Reex 2+
ADDITIONAL TESTING
HER2 FISH Global Tech-Only DNA Ploidy Global
Physician Noce: Only tests or diagnosc services that are medically necessary should be ordered. Appropriate ICD-10 informaon must be in the specied area above.
Payers, including Medicare and Medicaid, generally do not pay for screening tests.
Original and Second Copy (White / Canary) CSI Laboratories
Boom Copy (Pink) - Client
LEVEL OF SERVICE (REQUIRED - Please choose one): Global (with interpretaon) Slide Only (TC): glass slides only Web-Enabled (TC): digital images through e.CSI™
Specimen ID: Select Best Block
Body Site:
Formalin Fixed: Yes No Other Fixaon:
Cold Ischemia Time (min): Fixaon Time (hours):
Block(s): Slides: Other:
(ICD-10 informaon is required)
Collecon Date: Time: Date of Discharge:
IDC-10 Code(s):
Last Name: First Name: Middle Inial:
Gender: M F DOB: MRN:
Ordering Physician: Treang Physician:
Age:
A-1-ACT CD19 CK14 H. Pylori MART-1 PCP (Pneumocyss) Trypsin
A-1-AT CD1a CK17 HBcAg MDM2 PD-1 Tryptase (Mast Cell)
ACTH CD2 CK19 HBME-1 Melan-A PD-L1 SP263 (Imnzi®) TSH
Adenovirus CD20 (L26) CK20 HBsAg Mesothelin PD-L1 SP142 (Tecentriq®) TTF-1
AE1 CD21 CK5/6 HCG
Mismatch Repair (MLH1/
MSH2/MSH6/PMS2)
PD-L1 22c3
(Keytruda®/Libtayo®)
Tyrosinase
AE1/AE3 CD23 CK7 Hepatocyte (HepPar -1) Uroplakin II
AFP CD25 CK8 HER2 MOC-31 PHH3 Villin
ALK-1 (5A4) CD3 CK8/18 HHV-8 MPO
Prostate Triple Stain
(CK903+p63; Red p504S)
VImenn
Amyloid A CD30 (Ber-H2) CK903 HLA-DR MSA (Muscle Specic Acn) VIP
Annexin 1 CD31 D2-40 (Podoplanin) HMB-45 MUC1 PLAP VZV (Varicella Zoster)
AR (Androgen Rec.) CD33 DBA-44 hMLH-1 MUC2 PMS2 WT-1 (N-terminus)
Arginase-1 CD34 Desmin hMSH-2 MUC4 PR ZAP-70
ATRX CD38 DOG-1 hMSH-6 MUC5AC Prolacn
B72.3 (TAG72) CD4 E-cadherin hPL MUC6 PSA
BCL-1 (Cyclin D1) CD43 EBER by ISH HSV I/II MUM-1 PSAP
BCL-2 CD44 EBV LMP IgA MyoD1 PTH SPECIAL STAINS
BCL-6 CD45 (LCA) EGFR IgD Myogenin RCC (PNRA) AFB
Ber-EP4 CD5 EMA IgE Napsin A S100 Alcian Blue (pH2.5)
Beta-Catenin CD56 (NCAM)
Epi/myoepithelial
(CK5+CK14+p63+CK7/18)
IgG (p) NF S100p Alcian Blue + PAS
BG8 (Lewis Y) CD57 IgG4+IgG NKX3.1 SALL4 Colloidal Iron
BOB-1 (B Cell Specic
Octamer Binding)
CD61 ER IgM NSE SATB2 Congo Red
CD68 Factor VIII Inhibin OCT-2 SMM-HC EVG - Elasc
CAIX CD7 Factor Xllla INI-1 OCT-3/4 SMA GMS (Fungus)
CA 125 CD71 Fascin Insulin p120 Somatostan Gram
CA 19.9 CD79A Fli-1 Kappa p16 (CINtec) SOX-10 Iron
Calcitonin CD8 FSH
Kappa/Lambda IHC
Double Stain
p40 SOX-11 Mucicarmine
Caldesmon CD99 Galecn-3 p504S (AMACR) STAT-6 PAS without diastase
Calponin CDK4 Gastrin Kappa by ISH p53 Synaptophysin PAS with diastase
Calrenin CDX2 GATA -3 Ki-67 p57 TCL1 Reculin
CAM 5.2 CEA (m) GCDFP-15 Ki-67/CD138 IHC Double Stain p63 TdT Steiner
CD10 (CALLA) CEA (p) GFAP Lambda
Pan-Melanoma (HMB45/
Melan-A/Tyrosinase)
Thrombomodulin Trichrome
CD117 (c-KIT) Chromogranin A (m) GH Lambda by ISH Thyroglobulin Wright-Giemsa
CD123 Chromogranin A (p) Glucagon LEF-1 Parvovirus B19 TIA-1
CD138 Chymotrypsin Glycophorin A (CD235) LH PAX-2 Toxoplasma Gondii
CD15 (LeuM1) CMV Glypican-3 Lysozyme (Muramidase) PAX-5 TRAcP
CD163 c-MYC Granzyme B Mammaglobin PAX-8 Treponema Pallidum
Hospital status when specimen collected (must choose one): Hospital Inpaent Hospital Outpaent Non-Hospital Outreach / Clinic Paent
Prior Authorizaon Number:
Bill to: Client Bill Insurance Paent/Self Pay Split Bill: Client (TC) and Insurance (PC)
Bill charges to other hospital/facility:
Account Name & C-Number
PLEASE CALL CSI CLIENT SERVICES AT (800) 459-1185 TO INQUIRE ABOUT TESTS NOT LISTED ON REVERSE
SPECIMEN REQUIREMENTS SHIP SPECIMENS WITH COLD PACK
FISH* Formalin-Fixed Paran-Embedded Tissue Minimum 0.2 x 0.2 x 0.2 cm ssue; non-decalcied ssue only (FISH only).
IHC 1 H&E slide with its corresponding paran block (10% neutral buered formalin) - Preferred.
*For tech-only services, include 1 marked H&E slide (all at 4 microns). MUST CIRCLE AREA OF INTEREST ON H&E SLIDE.
CSI_09192021
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IHC Requisition INSURANCE BILLING INFORMATION - REQUIRED:

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Completed 18 June 2022

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