Gender: M F

Requisition Number:Your Specimen Number:__________________

Pick Up Confirmation #:__________________

LIST OF DISEASES & FINDINGS

Fax: 201.599.9066

Fax: 866.369.411425 Riverside Drive, Suite #2, Pine Brook, NJ, 07058 www.siparadigm.com

DISEASES & FINDINGSHEMATOLOGIC

ALL ( MRD)MDSAML ( LLC MRD)

MPNCML, Follow-up CML, New diagnosis

Myeloma ( MRD) Hodgkin Lymphoma

Marrow infiltration

Anemia

STAT/ RUSH

LEVEL OF SERVICE

Complete Consult: Hematopathologistselects clinically pertinent tests

Perform marked tests only (Results with interpretation)

Technical Only (Results without interpretation) Call us to discuss appropriate testing

siPortfolio

SPECIMEN INFORMATION

Collection Date:

Sent Date:

Time:

CBC results attached

HEMATOPATHOLOGY TEST REQUISITION FORM (INFORMATION WRITTEN IN RED IS MANDATORY)

BILLING INFORMATION

Insurance

Hospital Outpatient

Client Patient Hospital Inpatient

PATIENT INFORMATION

Name:

DOB: (mm/dd/yy)

Street:

City: State: ZIP:

Med Rec #/ Patient ID/SSN #: Phone #:

PHYSICIAN INFORMATION

Referring MD:

MGUSLymphoma (NHL)

PNH

Atypical WBCs Eosinophilia Erythrocytosis LeukocytosisLeukopenia Lymphadenopathy Lymphocytosis Thrombocytopenia Thrombocytosis

Other:

List individual antibodies in clinical information box above (menu on back)

IMMUNOHISTOCHEMISTRY (IHC & CISH) siPortfolio-CYTO

FLOW CYTOMETRY

Myeloid Lymphoid Karyotyping

FISH ALL AML CLL CMLLPD MDS MPN

EosinophiliaMyeloma

Lymphoma:

Acute Leukemia

LGL (T/NK)

LPD

ALL ( MRD)

AML CLL ( MRD)

Hairy Cell Leukemia

LPL (Waldenström) Lymphoma ( B T) Lymphocyte subsets MDSMPNMyeloma ( MRD) PancytopeniaPNH

MOLECULARHematology NGS Panels

Pan-Myeloid Panel Pan-Lymphoid Panel (17 Genes)

JAK2 V617F with reflex to Exons 12, 13 and 15JAK2 V617F with reflex to CALR & MPL

Individual Genes

JAK2 V617F with reflex to CALR, MPL & 69 Gene NGS Panel

Reflexes

CLINICAL INFORMATION

ICD-10

Authorized Signature: Date:

The undersigned certifies that he/she is licensed to order the test(s) listed below and that such test(s) are medically necessary. By signing below, I have obtained patient’s informed consent for the requested tests.In case of Solid Tumor testing, the signature below authorizes the release of the patient’s specimen block/slides from its collection (holding) facility.

Non-Hospital Patient

Call resultsNeed results by: --- / --- / ------

L A S T F I R S T,

LIST OF INDIVIDUAL TESTSCYTOGENETICS

siPortfolio-MOLECULAR

siPortfolio-IHC

siPortfolio-FLOW

69 Genes (40 DNA & 29 RNA)

Attach clinical notes, patient information & copies of both sides of insurance card

MMR

Fixation Time: Fixative: Cold Ischemia Time:

Predictive/prognostic hormonal markers

ERPgRKi-67

HER-2/neu, IHCHER-2/neu, FISHHER-2/neu IHC with reflex to FISH Burkitt

Mantle

MZL/MALTDLBCL

WaldenströmFollicular

BCR-ABL Major, Quantitative with reflex to MinorBCR-ABL Major, Quantitative with reflex to ABL-Kinase Mutation

BCR-ABL Major, Quantitative with reflex to Minor & ABL-Kinase Mutation

Account Information:

(See complete menu on back of requisition)

AML

CML

CMML

CNL

ET

JMML

MDS

MPN

CLLB-Lymphoproliferative disorderB-Lymphomas

Waldenström

P.vera

PMF

Mantle

Continental US: Tel: 888.599.LABS(5227) PR/International: Tel: 888.782.5430

ABL Kinase Mutation (CML)

BCR-ABL, Major (CML)

BCR-ABL, Minor (ALL)

B-Cell Gene Rearrangement

BRAF

CALR

CEBPA

IGHV

FLT3

JAK2 Exon 12

JAK2 V617F

JAK2 Exons 13 & 15

MPL

MYD88

NOTCH1

NPM1

T-Cell Gene Rearrangement

TP53

PML-RARA

cKIT

SF3B1

PD-L1 22C3 FDA (KeytrudaTM)PD-L1 28-8 FDA (OpdivoTM)PD-L1 SP142 FDA (Tecentriq TM)

Other:

Other:

Other:

Bone Marrow, (tube #) ( )Fresh Tissue/Fluid, (tube #) ( ) Formaline Container # ( )Urine Containers #

Peripheral Blood, (tube #) ( )Site:Paraffin Blocks # ( ) Slides # ( )Other # ( ) Specify: ( )

F001

-01

DETAILED MENU: PLEASE DO NOT MARK ON THIS PAGE

1p36/1pTEL/1q25

ALK (Break Apart)

ATM/TP53

BCL2/IGH

BCL6 (Break Apart)

BCR/ABL

BIRC3/MALT1

CBFB (Break Apart)

CEP12/D13S319/13q34

CEP15

CEP3

CEP8

CEP9

CEPX/CEPY

CSF1R/D5S23:D5S721

D13S319/13q34

D20S108

D7S486/CEP7

ETV6 (Break Apart)

ETV6/RUNX1 (TEL/AML1)

FGFR1 (Break Apart/ Amp.)

FIP1L1/CHIC2/PDGFRA

HER-2/neu (PathVysionTM)

IGH (Break Apart)

IGH/CCND1

IGH/FGFR3

IGH/MAF

IGH/MAFB

IGH/MYC/CEP8

MLL (Break Apart)

MYB

MYC (Break Apart)

TP53

PDGFRB (Break Apart)

PML/RARA

RUNX1T1/RUNX1 (ETO/AML1)

AFB Alcian Blue Alcian Blue/PAS Amyloid Giemsa

PAS (Fungus) GMS H&E Iron Mucicarmine

Pap PAS diastase Reticulum Trichrome Wright Giemsa

Fusion Driver Genes (29)

ABL1

ALK

BCL2

BRAF

CCND1

CREBBP

EGFR

ETV6

FGFR1

FGFR2

FUS

HMGA2

Full Genes (17)U2AF1

WT1

ASXL1

BCOR

CALR

CEBPA

ETV6

EZH2

IKZF1

NF1

PHF6

PRPF8

RB1

RUNX1

Actin (muscle spec.)

Actin (sm. muscle)

ADH-5

ALK-1

CA 125

CA 19.9

Caldesmon

Calponin

Calretinin

CAM 5.2 (CK8/18)

CD1a

CD2

CD3

CD4

CD5

CD7

CD8

CD10

CD15

CD20

CD21

CD23

CD30

CD31

CD34

CD43

CD45 (LCA)

CD56

CD57

CD61

CD68

CD71

CD79a

CD99

CD117

CD138

CDX2

CEA, Monoclonal

CEA, Polyclonal

Chromagranin A

CK5/6

CK7

CK17

CK19

CK20

CK903

CMV

C-MYC

D2-40

Desmin

EBER (ISH)

E-Cadherin

Estrogen Receptor (ER)

Fascin

FVIII (von Willebrand)

FXIIIa

GATA3

GCDFP-15

GFAP

Glycophorin A (CD235)

Glypican-3

Granzyme B

H. pylori

HBME-1

Hepatocyte (HepPar1)

HER-2/neu

HHV-8

HMB45

HNF1ßHPV-HR

HPV-LR

HSV-1

HSV-2

IgA

IgG4

IgG

IgM

Inhibin

Kappa (IHC)

Kappa (ISH)

Ki-67

Lambda (IHC)

Lambda (ISH)

Lysozyme

Mammaglobin

Melan A

MiTF-1

MOC-31

MUM-1

Myeloperoxidase

MLH 1

MSH 2

MSH 6

Napsin A

NSE

OCT2

OCT4

PMS2RCC

S100

SMMS-1SOX-10

SOX-11Synaptophysin

TdT

Thrombomodulin

Thyroglobulin

TIA-1

TRAP

TTF-1Tyrosinase

Uroplakin-IIIVimentinWT-1

Expression Genes (5)

MLLT3

NUP214

PDGFRA

PDGFRB

RARA

RBM15

RUNX1

TCF3

TFE3

BAALC

MECOM

MYC

SMC1A

WT1

ABL1

BRAF

CBL

Hotspot Genes (23)CSF3R

DNMT3A

FLT3

GATA2

HRAS

IDH1

IDH2

JAK2

KIT

KRAS

MPL

MYD88

NPM1

NRAS

PTPN11

SETBP1 SH2B3

STAG2

TET2

TP53

JAK2

KMT2A (MLL)

MECOM

EBER (EBV) Kappa (ISH)

HPV (HR & LR) Lambda (ISH)

SPECIAL STAINS

FLOW CYTOMETRY MENU

IN SITU HYBRIDIZATION (ISH)

FLUORESCENCE IN SITU HYBRIDIZATION (FISH) MENU

PAN-MYELOID NGS PANEL (69 GENES)

IMMUNOHISTOCHEMISTRY (IHC) MENU

SF3B1

SRSF2

ZRSR2

MET

MLLT10

PAN-LYMPHOID NGS PANEL (17 GENES)ATM BTK BIRC3 CARD11 CD79B DDX3XFBXW7 MAPK1 MYD88 NOTCH1 PIK3CA

PIK3CD

PTEN

PTPN6 SF3B1 TP53 XPO

MYH11

MYBL1

NTRK3

www.siparadigm.com Fax: 201.599.9066

Fax: 866.369.411425 Riverside Drive, Suite #2, Pine Brook, NJ, 07058

IGHV

HEREDITARY CANCER NGS PANEL

SOLID TUMOR NGS PANEL

PLEASE USE THE DEDICATED HEREDITARY CANCER REQUISITION

PLEASE USE THE DEDICATED SOLID TUMOR REQUISITION

PCM1/JAK2

CD1aCD2CD3CD4CD5

CD26CD27CD28CD30

CD33CD105CD117CD123CD138

CD200CD71cCD79aCD79bCD81

CD103CD58CD59CD61CD64

CD65CD45CD49dCD52CD56

CD57CD34CD36CD38CD41

CD43CD20cCD22CD23CD24

CD25CD13

CD14CD15CD16

CD19CD7CD8CD10CD11bCD11c

CD235a (Glyco)

FLAERHLA-DRcIgA

cIgGcIgMKappa

cMPO

nTdT

ZAP-70

UroVysionTM Bladder Cancer

ALK Break Apart NSCLC

ROS1 Break Apart NSCLC

(IMMUNOHISTOCHEMISTRY)

Continental US: Tel: 888.599.LABS(5227) PR/International: Tel: 888.782.5430

TCR γ/δ TCR α/ß

LambdacKappa

cLambdacCD13

p16

p40

p504S

p53

p57

p63

p120 Catenin

PAX-5

PAX-8

PCK (AE1/AE3)

PD-1

PD-L1 (22C3)

PLAP

PSAPSAPPSMA

PgR Progesterone receptor

PIN4

PD-L1 (28-8)

PD-L1 (SP124)

Annexin A1

Arginase

B72.3/TAG-72

bcl-1

bcl-2

bcl-6

BerEP4

Beta HCG

Bg8

Bob.1

Alpha-1 fetoprotein (AFP)

Amyloid-A

BRAF

ALK (D5F3)

F001

-01