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LABORATORY TEST REQUISITION FORM

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Collagen Diagnostic Laboratory Test Requisition (November 2019)
UW LABORATORY FOR PRECISION DIAGNOSTICS
Peter H. Byers, MD, University of Washington, Lab H-561 Health Sciences, 1959 NE Pacific St, Seattle, WA 98195
Main Phone (206) 543-0459; Genetic Counselors (206) 543-5464; Fax (206) 616-1899; www.uwcpdx.org
LABORATORY TEST REQUISITION FORM
NAME:
DOB:
SEX: MALE FEMALE
YOUR PATIENT ID#:
ADDRESS:
CITY: STATE:
ZIP:
PHONE:
Blood (PREFERRED) 5-7cc, purple top EDTA
DNA (minimum 3µg for pa
nel, 1µg for known )
Saliva
Amniocytes (2 T25-flasks, cultured)
CVS Cells
(2 T-25 flasks, cultured)
Stored cells (CDL Repository)
Other: ________________________
RE
FERRING PHYSICIAN (REQUIRED):
NAME:
NPI #:
PHYSICIAN SPECIALTY:
GENETIC COUNSELOR:
INSTITUTION:
ADDRESS:
CITY: STATE: ZIP:
COUNTRY:
PHONE:
FAX:
EMAIL:
REFERRING LAB:
SEND OUT COORDINATOR:
ADDRESS:
CITY: STATE: ZIP:
COUNTRY:
PHONE:
FAX:
SUSPECTED DIA
GNOSIS:
Osteogenesis Imperfecta Ehlers-Danlos Syndrome Marfan Syndrome Loeys-Dietz Syndrome
Familial Aneurysm Syndrome Other:
CLINICAL DESCRIPTION – PLEASE ATTACH CLINIC NOTE:
Blue sclerae Hearing Loss High arched palate Lens dislocation Dentinogenesis Imperfecta
Translucent skin
Easy bruising
Atrophic scarring
Bifid Uvula
Dural ectasia
Scoliosis
Bone deformity
Short Stature
Joint hypermobility
Joint dislocations
Congenital contractures
Fractures (age and location):
Vascular Event: dissection, aneurysm, rupture (age and location):
Other findings/history:
Positive family history (please include pedigree)
Special Instructions and Additional Information (if prenatal, include EDD):
At CDL, we are committed to excellence in health care, biomedical education and research. To this end we may use
submitted clinical information and remaining specimens to better understand disease mechanism, to improve laboratory
testing and for educational purposes. De-identified data from tested individuals may be submitted to clinical genetic
data registries and/or for publication. Individuals may refuse to allow CDL to use their information and specimen by
signing below. A description of this testing policy and research approach is available at www.uwcdl.org
OPT OUT SIGNATURE DATE
CLINICAL INFORMATION – PLEASE ATTACH CLINIC NOTE
PATIENT INFORMATION REPORTING RESULTS
SAMPLE TYPE:
Page 1 of 3
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Osteogenesis Imperfecta (OI) and genetic bone disorders
Autosomal Dominant OI Panel (COL1A1, COL1A2, IFITM5)
☐
OI and Genetic Bone Disorders Panel
☐
☐
☐
(ALPL, B3GAT3, B4GALT7, BMP1, COL1A1, COL1A2, CREB3L1, CRTAP, FAM46A/TENT5A, FGFR3, FKBP10, GORAB,
IFITM5, LRP5, MBTPS2, MESD, NBAS, P3H1, P4HB, PLOD2, PLOD3, PLS3, PPIB, RUNX2, SEC24D, SERPINF1, SERPINH1,
SP7, SPARC, TAPT1, TMEM38B, TNFRSF11B, WNT1, XYLT2)
Individual Genes:
COL1A1 and COL1A2
IFITM5
☐
☐
Caffey Disease (COL1A1 c.3040C>T), Sanger sequencing
X-Linked Osteoporosis (PLS3)
Osteopetrosis Panel
(AMER1, CA2, CLCN7, CTSK, FAM20C, FERMT3, LEMD3, LRP5, OSTM1, PLEKHM1, SNX10, TCIRG1, TNFRSF11A, TNFSF11)
Classical and Vascular EDS Panel (COL5A1, COL5A2, COL3A1)
Classical EDS (COL5A1 and COL5A2)
Vascular EDS (COL3A1)
Arthrochalasia EDS (Exon 6 COL1A1/COL1A2), Sanger sequencing
Dermatosparaxis EDS (ADAMTS2)
Kyphoscoliotic EDS (PLOD1 and FKBP14)
Periodontal EDS (C1S and C1R)
Complex EDS-like Disorders
(B3GALT6, B4GALT7, B3GAT3, CHST14, CHST3, XYLT1)
Arterial Aneurysm Panel
(ACTA2, BGN, CBS, COL1A1, COL3A1, FBN1, FBN2, FOXE3, LOX, MAT2A, MFAP5, MYH11, MYLK, NOTCH1, PLOD3,
PRKG1, SKI, SLC2A10, SMAD2, SMAD3, SMAD4, SMAD6, TGFB2, TGFB3, TGFBR1, TGFBR2)
Marfan Syndrome and Loeys-Dietz Syndrome Panel (FBN1, SMAD2, SMAD3, SMAD4, TGFB2, TGFB3, TGFBR1, TGFBR2)
COL4A1 and COL4A2 Related Disorders (COL4A1 and COL4A2)
2
)
Cutis Laxa Panel
(ALDH18A1, ATP6V0A2, ATP6V1A, ATP6V1E1, ATP7A, EFEMP2, ELN, FBLN5, GORAB, LTBP4, PYCR1, RIN2, SLC2A10)
(ADAMTS10, ADAMTS17, ADAMTSL4, CBS, FBN1)
Alport Syndrome
Alport Syndrome Panel
(COL4A3, COL4A4, COL4A5)
X-Linked Alport Syndrome (COL4A5)
Stickler Syndrome
Page 2 of 3
Collagen Diagnostic Laboratory Test Requisition
Targeted pre-mRNA Splicing Analysis (cultured fibroblasts required)
Maternal Cell Contamination Studies (fragment analysis)
Ectopia Lentis Panel
Known Mutation/Variant Testing
Name of Relative (Proband):
Relationship to Proband:
(Please provide copy of report if testing done at another laboratory)
CDL#:
Gene:
Mutation/Variant:
Ehlers-Danlos Syndromes (EDS)
Vascular Genetic Disorders
TEST REQUESTED (See website for current costs and CPT codes)
Comprehensive EDS Panel (ADAMTS2, ATP7A, C1R, C1S, CHST14, COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, DSE,
FKBP14, FLNA, PLOD1, SLC39A13)
☐
☐
☐
Mutation/Variant:
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Marfan syndrome (FBN1)
☐
☐
☐
☐
☐
☐
Stickler Panel (COL2A1, COL9A1, COL9A2, COL9A3, COL11A1, COL11A2)
☐
Panels and single gene tests include both sequencing and deletion/duplication analysis by next-generation sequencing
Other Tests
BILLING
INFORMATION
Requested laboratory testing will be initi
ated only AFTER accurate billing information is provided.
Canadian samples: Providers must acquire approval of all tests, including reflex testing, before submitting samples.
State:
BILL INSTITUTION: INSTITUTIONAL
BILLING
Institution Name:
Tax ID Number: PO#:
City: ZIP:
Phone: Fax:
Send
Result Report:
BILL PATIENT: SELF-PAY or INTERNATIONAL SAMPLES
Check (payable to UW Physicians) or Money Order Amount (USD):
Credit Card: Please contact CDL billing at (206) 685-5007 to provide credit card information over a secure line.
Electronic Funds Transfer (EFT)
(See website for details) EFT Amount: USD
BILL INSURANCE: PATIENT INSURANCE *Patient needs to sign billing consent below*
Preauthorization is required for all insurance billing over $600.00 (note testing is not started until pre-authorization complete)
Relationship to Patien
t: Self Parent Spouse Other (please specify):
Cardholder DOB: Dates of Coverage:
Patient Policy ID#:
Group Name: Group #:
Insurance Co. Name:
Claims Billing Address:
*Patient Insurance Billing Consent:
I authorize t
he CDL to release to my designated insurance carrier, health plan, or third party administrator the information on this form and any other information provided by
my health care provider necessary for reimbursement. I assign and authorize insurance payments to the CDL. I understand my insurance carrier may not approve and
reimburse my medical genetic services in full due to usual and customary rate limits, benefit exclusions, coverage limits, lack of authorization, medical necessity, or otherwise.
I understand I am responsible for fees not paid in full, co-payments, and policy deductibles except where my liability is limited by contract or State or Federal law. A duplicate
or faxed copy of this authorization is considered the same as the original document.
Patient Signature: Date:
BILL MEDICARE: Medicare does not pre-authorize under any circumstances.
A compl
eted Advance Beneficiary Notice (ABN) is required for Medicare patients (see website).
SHIP SAMPLE OVERNIGHT TO:
Peter H. Byers,
MD
UW Laboratory for Precision Diagnostics
H-561, Health Science
Bldg.
1959 NE Pacific
Street
Seattle, WA
98195
Page 3 of 3
Collagen Diagnostic Laboratory Test Requisition
Do insurance preauthorization PROCEED if approved; include PreAuth
Form. Clinic notes are required.
Preauthorization already obtained; PreAuth approval#____________________________________ Attach copy of P.A.
No Preauthorization needed (for tests less than $600.00; confirm patient signs below)
Please attach a copy of card for all insurance billing
Name on Policy:
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LABORATORY TEST REQUISITION FORM

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Completed 24 May 2022

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