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TEL # 1-888-"ACUPATH" (228-7284) TEL # (516) 775-8103 FAX # (516) 326-3452 28 S. TERMINAL DRIVE, PLAINVIEW, NY 11803 WWW.ACUPATH.COM

"FOR THE ABSOLUTE HIGHEST STANDARD"© 2009

hospital pathology request form

HOS-A

ANY OMISSION MAY RESULT IN DELAY OF REPORT

STAT

SPECIMEN INFORMATION

Collection Date: ________________ Collection Time: ________________

SPECIMEN ID(S): ________________ ICD-9 CODE: ____________________

SITE: ______________________________________________________________ CLINICAL DATA/HISTORY: __________________________________________ ____________________________________________________________________ ____________________________________________________________________

PATIENT INFORMATION

SS#

RACE (optional) M F DATE OF BIRTH

LAST NAME STREET ADDRESS CITY TEL. #

FIRST NAME

M.I.

STATE CHART / A/C # In-Patient Out-Patient

ZIP

DIAgNOSIS TYPE: New Diagnosis Relapse In Remission MULTIPLE SPECIMENS: Test All Select best block and/or specimen SPECIMEN TYPE: Blood: Green top(s):_____ Purple top(s):_____ Smears:_____ Bone Marrow: Green top(s):_____ Purple top(s):_____ Core Biopsy:_____ Clot:_____ Smears:_____ Other: ______________________ Urine: Voided Bladder Washing Fluid: FNA CSF Other: ______________________________________ Tissue Biopsy Fresh Tissue # of Paraffin Block(s)/Specimen Containers:____________ Fixative: Formalin Other: _______________________________________

DIAgNOSTIC, PROgNOSTIC, AND THERAPEUTIC ANALYSES

Non-Hospital Patient

Patient Status (select one):

HISTOPATHOLOgY AND IHC

HISTOPATHOLOgY IHC Staining (Technical Component Only) IHC Staining and Interpretation Virtual IHC - Stain and Scan Virtual IHC - Stain, Scan and Image Analysis Perform the selected antibodies acquired from antibody list: ______________________________________________________________________ Perform the appropriate panel for the following differential diagnosis under consideration: ______________________________________________________________________ DIRECT IMMUNOFLUORESCENCE (DIF)

PATIENT'S PRIMARY INSURANCE

BILL TO MEDICARE BILL TO PATIENT BILL TO HOSPITAL BILL TO OTHER NO FAULT WORKERS COMP INSURED'S NAME: _____________________________________D.O.B. __________________ / / DATE OF ACCIDENT (IF NO FAULT/WORKERS COMP) _____________________________ / / PT RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER

POLICY #____________________________________SS # _____________________________ GROUP NAME #_________________________________ REFERRAL # _________________

NAME OF INSURANCE CO. ______________________________________________________ INSURANCE ADDRESS* ________________________________________________________ CITY _________________________________________ STATE _______ ZIP _______________ *If previous biopsy on file with Acupath and same insurance company, please check box SECONDARY INSURANCE INSURED'S NAME: _____________________________________D.O.B. __________________ / / PT RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER

SAMPLE

BREAST DIAgNOSTICS URO DIAgNOSTICS

ER/PR Ki67 p53 HER-2/neu (IHC) HER-2/neu by FISH, PathVysionTM 1+ 2+ 3+ DNA Ploidy/S Phase Fraction (from tissue biopsy/paraffin block only) Other ______________________________________________________________

Bladder Cancer Detection by FISH, UroVysionTM

Urine Cytology

FLOW CYTOMETRY

Comprehensive Flow Panel Acute Leukemia Lymphoma Multiple Myeloma CLL Diagnostic/Prognostic Profile Monitoring Treatment and Minimal Residual Disease (MRD) for: ______________________________________________________________________ INDICATE SPECIFIC FLOW ANTIBODIES: ______________________________ ______________________________________________________________________ LYMPH NODE ANALYSIS COMPLETE LYMPH NODE EVALUATION Flow Cytometry Studies Only

POLICY #____________________________________SS # _____________________________ GROUP NAME # _________________________________ REFERRAL # _________________ NAME OF INSURANCE CO. ______________________________________________________ INSURANCE ADDRESS* ________________________________________________________ CITY _________________________________________ STATE _______ ZIP _______________ *If previous biopsy on file with Acupath and same insurance company, please check box

I authorize the release to my insurance carrier of any medical information necessary to process this claim, and I authorize payment of medical benefits directly to ACUPATH Laboratories Inc. I also authorize release of my pathology results to my doctor utilizing all methods of transmission according to HIPAA regulations.

PATIENT'S SIgNATURE ON FILE Authorized Signature: ___________________________________________________________

CYTOgENETICS/HEMATOLOgIC FISH

Cytogenetics - Chromosome Analysis Proceed to the appropriate FISH panel for diagnosis under consideration: ______________________________________________________________________ ______________________________________________________________________

MOLECULAR

FOR OPTIMAL TESTINg: please provide one (1) lavender (EDTA) tube, 3-5 ml

Hematologic Molecular

BCR/ABL quantitative P190 P210 B/T cell clonality B cell T cell B/T cell BCL2 rearrangement PML/RARA JAK2 V617F quantitative FLT3/NPM1 MPL

FISH

AML FISH panel MPD FISH panel CLL FISH panel PML/RARA by FISH NHL FISH panel Multiple Myeloma FISH panel MDS FISH panel BCL2 rearrangement - t(14;18) BCR/ABL by FISH

Infectious Agents

HPV (ThinPrep® PreservCyt Solution) HPV ISH (from tissue biopsy/paraffin block) gonorrhea/Chlamydia (ThinPrep® PreservCyt Solution)

INDICATE SPECIFIC PROBES:_________________________________________ ______________________________________________________________________

TEL # 1-888-"ACUPATH" (228-7284) TEL # (516) 775-8103 FAX # (516) 326-3452 28 S. TERMINAL DRIVE, PLAINVIEW, NY 11803 WWW.ACUPATH.COM

"FOR THE ABSOLUTE HIGHEST STANDARD"© 2009

speCimeN requiremeNts for optimal testiNg ALL SPECIMENS SHOULD BE RECEIVED WITHIN 24 HOURS AFTER OBTAINED FROM PATIENT FOR OPTIMAL RESULTS

TEST

Blood

PERIPHERAL BLOOD

Smear Aspirate

BONE MARROW

Smear Clot Core

OTHER

Tissue / FNA / Lymph Nodes / CSF

BLOOD MORPHOLOgY

One (1) lavender (EDTA) tube (3-5 ml) 2-8° C

Two (2) bedside smears

BONE MARROW MORPHOLOgY

Two (2) bedside smears OR

Four (4) - Eight (8) bedside smears OR

>1 cm (length) in formalin

>1 cm (length) in formalin

One (1) lavender (EDTA) tube (1 ml) 2-8° C

One (1) aspirate lavender (EDTA) tube (1 ml) 2-8° C

FLOW CYTOMETRY

One (1) green (NaHeparin) tube (5-8 ml) room temp.

One (1) green (NaHeparin) tube (1-2 ml) room temp.

Tissue / FNA / Lymph Nodes In complete RPMI media Refrigerate

CSF in sterile container Refrigerate

DNA PLOIDY/S PHASE FRACTION

CYTOgENETICS/FISH

One (1) green (NaHeparin) tube (3-5 ml) room temp.

SAMPLE

One (1) green (NaHeparin) tube (1-2 ml) room temp. One (1) lavender (EDTA) tube (1-2 ml) 2-8° C

TISSUE /

Formalin-fixed tissue biopsy Formalin jar OR Paraffinembedded biopsy

BLADDER CANCER DETECTION BY FISH, UROVYSION®

40-50 ml voided urine, mixed in a 2:1 ratio with ThinPrep® PreservCyt Solution 4-8 °C

HER-2/NEU BY FISH, PATHVYSION®

Formalin-fixed tissue biopsy Formalin jar OR Paraffinembedded biopsy

MOLECULAR PATHOLOgY

One (1) lavender (EDTA) tube (Must provide 3-5 ml) 2-8° C

Formalin jar OR Paraffinembedded biopsy

HPV/gONORRHEA CHLAMYDIA

ThinPrep® PreservCyt Solution 4-8° C

HISTOPATHOLOgY/ IHC

Formalin jar OR Paraffinembedded biopsy

DIF

Michele's Fixative only. Tissue

Information

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