Carrier Screening Requisition for Providers
Laboratory Test(s) Being Ordered
Carrier Screening Tests
Expanded Carrier Screening (283 genes)
ECS 39 (39 genes)
ECS 152 (152 genes)
Sandhoff disease enzyme only
Tay-Sachs disease enzyme only
Comprehensive Jewish Carrier Screen (101 genes)
Standard Pan-ethnic Panel (4 genes)
High Frequency Pan-ethnic Panel (11 genes)
Ashkenazi Jewish Disorders (47+17 genes)
Sephardi-Mizrahi Jewish Disorders (37+17 genes)
Infertility/Pregnancy Loss:
Test for Microdeletions of Y Chromosome (male only)
Cystic Fibrosis with CFTR Intron 9 PolyT (male only)
Chromosome analysis
POC Microarray PLUS
Thrombophilia F2 - c. *97G>A
Thrombophilia F5 -c.1601G>A (p.Arg534Gln)
MTHRF - c.665C>T (p.Ala222Val) add-on
ICD-10 Diagnosis Code(s)
Z31.430 Encounter of female for testing for genetic disease carrier status for procreative management
Z31.440 Encounter of male for testing for genetic disease carrier status for procreative management
Z84.81 Family history of carrier of genetic disease
N96 Recurrent pregnancy loss (female)
Z31.441 - Encounter for testing of male partner of patient with recurrent pregnancy loss
Other
Please specify ICD-10 diagnosis code
Family History Of:
Patient Information
Patient Last Name
Patient First Name
Client MRN
Patient DOB (MM/DD/YYYY)
Patient Phone Number
Patient Email
Patient Address
Patient City/State/Zip
Biological Sex
Male
Female
Is the patient currently pregnant
?
No
Yes
Is the patient currently using birth control medication or hormone replacement therapy?
No
Yes
Is the patient's partner also being tested?
No
Yes
Partner Information
Partner Last Name
Partner First Name
Partner DOB (MM/DD/YYYY)
Patient Specimen Information
Specimen Requirements
Blood: One 5-10 mL ACD tube (yellow top) and two 5-10 mL EDTA tubes (lavender top)
Saliva: Saliva specimens are accepted in Oragene DNA (OG-500) kits by DNA Genotek. Please note that Tay Sachs enzyme analysis cannot be performed on saliva
Patient Specimen Type
Blood
Saliva
Products of Conception
Other
Please specify specimen type
Date of Collection (MM/DD/YYYY)
Financial Responsibility
Insurance Carrier
Is the patient the policyholder?
No
Yes
Policyholder Name (Last, First)
Policyholder DOB (MM/DD/YYYY)
Insurance ID
Group Number
Referring Provider Information
Provider Name (First, Last, Credential)
eg. John Smith, MD
Provider Practice Name
Provider Practice Address
Provider City / State / Zip Code
PROVIDER SIGNATURE CONSENT:
I certify that this patient (and/or their legal guardian, as necessary) has been informed of the benefits, risks, and limitations of the laboratory test(s) requested. I have answered this person's questions. I have obtained a signed information consent from this patient or their legal guardian for this testing in accordance with applicable laws and regulations, including N.Y. Civil Right Law Section 79-L, and will retain this consent in the patient's medical record.
Yes, I have read and agree.
Provider Consent Date (MM/DD/YYYY
)
Contact Information