Noninvasive Prenatal Testing (NIPT) Requisition
Must be at least 9 weeks gestation for NIPT.
Specimen Requirements: Two 10 mL Whole Blood BCT Streck Tubes
NIPT tests being ordered
Standard (chromosomes 13, 18, 21, and Fetal Sex
Standard Plus ("Standard" plus chromosomes 15, 16, 22, and sex chromosome aneuploidies X, XXX, XXY, XYY)
Expanded ("Standard Plus" with microdeletions 22q11.2, 1p36, 4p16, 5p15, 15q11.2-q13, 8q24, and 11q23)
OMIT FETAL SEX
Sequenom MaterniT GENOME (Standalone test): Genome-wide fetal aneuploidies (singleton only)
NIPT Required Clinical Information
Gestational Age (Weeks & Days or EDD)
Maternal Height (Ft & In)
Maternal Weight (lbs)
Is this a repeat test for low fetal fraction?
NIPT Indications for Testing
High Risk for fetal chromosomal aneuploidies?
ICD-10 Diagnosis Code(s) - High Risk
O09.511: Advanced Maternal Age, Primigravida, 1st trimester
O09.512: Advanced Maternal Age, Primigravida, 2nd trimester
O09.513: Advanced Maternal Age, Primigravida, 3rd trimester
O09.521 Advanced Maternal Age, Multigravida, 1st trimester
O09.522 Advanced Maternal Age, Multigravida, 2nd trimester
O09.523 Advanced Maternal Age, Multigravida, 3rd trimester
O28.1: Abnormal serum biochemical screening
O35.1XX0: Abnormal ultrasound finding
O09.291: Prior pregnancy with trisomy, 1st trimester
O09.292: Prior pregnancy with trisomy, 2nd trimester
O09.293: Prior pregnancy with trisomy, 3rd trimester
Q95.0: Chromosome transversion
Q95.1: Chromosom inversion
Please specify abnormal biochemical screening results.
Please specify ICD-10 diagnosis code
Please specify abnormal ultrasound findings:
Please specify other high-risk factor (ICD-10 code)
ICD-10 Diagnosis Codes, non-High Risk
Z34.91: Supervision of normal pregnancy, 1st trimester
Z34.92: Supervision of normal pregnancy, 2nd trimester
Z34.93: Supervision of normal pregnancy, 3rd trimester
Patient Last Name
Patient First Name
Patient DOB (MM/DD/YYYY)
Patient Phone Number
Is the patient the policyholder?
Policyholder Name (Last, First)
Policyholder DOB (MM/DD/YYYY)
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