HEMATOLOGY/ONCOLOGY

When ordering tests for which Medicare or Medicaid reimbursements will be sought, physicians should order only those tests

that are medically necessary for the diagnosis or treatment of the patient.

CLIENT INFORMATION

ORDERING PHYSICIAN NPI #

TREATING PHYSICIAN NPI #

PHYSICIAN/AUTHORIZED SIGNATURE

PATIENT INFORMATION

Name (LAST, FIRST, MI):

Date of Birth:

Sex: ¨ Male ¨ Female

Address:

City, State, Zip:

Phone Number:

Med. Rec. # / Patient #:

BILLING INFORMATION (attach face sheet and copy of insurance card – both sides)

Bill: ¨ My Account ¨ Insurance ¨ Medicare ¨ Medicaid ¨ Patient ¨ Workers Comp

Patient Hospital Status: ¨ In-Patient ¨ Out-Patient ¨ Non-Patient

Insurance Information: ¨ See attached Authorization # __________________________

PRIMARY BILLING PARTY SECONDARY BILLING PARTY

INSURANCE CARRIER INSURANCE CARRIER

ID # ID #

GROUP # GROUP #

INSURANCE ADDRESS INSURANCE ADDRESS

NAME OF INSURED PERSON NAME OF INSURED PERSON

RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT

EMPLOYER NAME EMPLOYER NAME

*IF MEDICAID STATE PHYSICIAN’S PROVIDER #

WORKERS

COMP

¨ Yes ¨ No

SPECIMEN INFORMATION

Collection Date: Time: ¨ AM ¨ PM

Specimen ID #(s):

Body Site/Descriptor:

Fixative:

¨ 10% Neutral Buffered Formalin ¨ Other: Hours Fixed:

Specimen Type: Smears:

¨ BM Aspirate ¨ Fluid: ¨ Peripheral Blood #

¨ BM Clot ¨ FNA: ¨ BM Touch Preps #

¨ BM Core ¨ CSF ¨ BM Aspirate #

¨ Dry Tap ¨ Lymph Node: ¨ Effusion #/Source

¨ Peripheral Blood ¨ Slides # ¨ Fresh Tissue #/Site

If slide procurement required, indicate below:

Facility Name:

Address:

Phone Number:

Fax Number:

CLINICAL INDICATION FOR STUDY (attach clinical history and pathology reports)

Narrative Diagnosis/Clinical Data

(please include Pathology report with diagnosis, indication for study, and previous test results)

All diagnoses should be provided by the ordering physician or an authorized designee.

Diagnosis/Signs/Symptoms in ICD-CM format in effect at Date of Service (Highest Specificity Required)

ICD-CM ICD-CM ICD-CM

¨ Acute Lymphoblastic Leukemia

¨ B-cell ¨ T-cell

¨ Lineage Uncertain

¨ Acute Myeloid Leukemia

¨ Anemia

¨ Chronic Lymphocytic Leukemia

¨ Chronic Myelogenous Leukemia

¨ Hodgkin Lymphoma

¨ Leukemia, Unspecified

¨ Leukocytosis, Unspecified

¨ Leukopenia

¨ Lymphadenopathy

¨ Monoclonal Gammopathy

¨ Myeloma, Plasma Cell

¨ Myelodysplastic Syndrome

¨ Myeloproliferative Neoplasm

¨ Non-Hodgkin Lymphoma

¨ Polycythemia

¨ Suspected malignant neoplasm

¨ Thrombocytopenia

¨ Thrombocytosis

Disease Stage/Clinical Course:

¨ New Diagnosis ¨ Relapse ¨ Follow-Up ¨ Other:

¨Post Treatment: ¨ Radiation ¨ Chemotherapy ¨ BM Transplantation Donor: ¨ M ¨ F

Patient, client, and billing information is requested for timely

processing of this case. Medicare and other third party payors

require that services be medically necessary for coverage,

and generally do not cover routine screening tests.

SPECIMEN LABEL INSTRUCTIONS

1. Complete the requisition with all

requested information.

2. Label specimen with two unique identiﬁ ers.

3. Remove the required number of labels

from the front of this sheet.

4. Place one (1) label on each specimen

container (not on the lid).

Please dispose of unused labels.

When ordering tests that are subject to ABN guidelines,

refer to the policies published by your Medicare

Administrative Contractor (MAC), CMS, or

www.Labcorp.com/MedicareMedicalNecessity.

Symbols Legend

@ = Subject to Medicare medical necessity guidelines

^ = Medicare deems investigational. Medicare does not pay

for services it deems investigational.

For pediatric patients ONLY: ¨ COG Study ¨ COG Post Treatment

IntelliGEN

NGS Assay (see reverse for gene list; bone marrow or peripheral blood)

¨ IntelliGEN

Myeloid for AML, MDS, MPN

Indication: __________________________________________________________________

clonoSEQ

NGS Assay for MRD for Multiple Myeloma, CLL, B-ALL (Billed by Adaptive Biotechnologies)

Indication: _____________________________________________________________________

Specimen types: Blood or bone marrow. For blood or fresh bone marrow aspirate, use a lavender-top

(EDTA) tube only. clonoSEQ ID test for Multiple Myeloma requires bone marrow.

¨ clonoSEQ ID. Must be run first to establish baseline. Performed using a high disease burden

diagnostic specimen (fresh or archived). If diagnostic specimen is not accompanying this order

complete Procurement information in SPECIMEN INFORMATION section. For CLL/SLL, IGHV mutation

status will be reported.

¨ clonoSEQ MRD. Performed using fresh specimen collected during or after treatment. Patient must have

had a previous clonoSEQ ID test performed. If not, please also check clonoSEQ ID above.

If clinical indication is not Multiple Myeloma, CLL, or B-ALL, please complete and submit an ABN,

found at www.clonoseq.com/for-clinicians/ordering.

♦ Peripheral blood only

clonoSEQ is a registered trademark of Adaptive Biotechnologies www.adaptivebiotech.com

ᵜ

If sending DNA, the lab only accepts isolated or extracted nucleic acids for which extraction or isolation is performed in an appropriately qualified

CLIA or CAP/CMS equivalent laboratory.

COMPREHENSIVE HEMATOPATHOLOGY ANALYSIS

(Peripheral Blood or Bone Marrow)

MORPHOLOGIC EVALUATION

(include a copy of CBC report)

¨ Bone Marrow Morphology ¨ Peripheral Blood Morphology

FLOW CYTOMETRY

(see reverse for antibody list)

¨ Hematolymphoid Neoplasia Assessment (HNA)

¨ Add diagnostic tests

per IO Reflex Criteria (see reverse)

¨ Add prognostic tests

per IO Reflex Criteria (see reverse)

¨ DNA Ploidy/S-Phase Assessment

¨ Leukocyte Adhesion Deficiency Assessment♦

¨ BAL CD4:CD8 Assessment

¨ ZAP70/CD38/CD49d Assessment

¨ PNH ♦

¨ Stem Cell Enumeration

¨ CLL MRD

¨ ALL MRD

(meets COG requirements)

CYTOGENETICS

¨ Cancer Cytogenetics ¨ Constitutional Cytogenetics

‡

FISH

(select disease state profile OR individual probes)

MOLECULAR

Acute Leukemia

¨ FLT3 Mutation

¨ IDH 1/2 Mutation

¨ CEBPA Mutation

¨ NPM1 Mutation

¨ PML/RARA

(Quantitative)

¨ cKIT Mutation

¨ LeukoStrat

CDx

FLT3 Mutation

Lymphoid Neoplasm

¨ B-cell Rearrangement IgH/IgK

¨ T-cell Rearrangement TRG/TRB

¨ B-cell Rearrangement IgH

¨ B-cell Rearrangement IgK

¨ T-cell Rearrangement TRG

¨ T-cell Rearrangement TRB

¨ BCL1 Rearrangement

¨ BCL2 Rearrangement

¨ IgVH Mutation

¨ p53 (CLL/B-cell ONLY)

¨ BRAF Mutation

¨ MYD88 Mutation

MPN/CML/Mastocytosis

¨ BCR/ABL1 Quantitative

¨ ABL Kinase Domain

Mutation

(BCR/ABL will be run)

JAK2 V617F Mutation

¨ Qualitative ¨ Quantitative

if negative reflex to:

¨ CALR

JAK2 Exon 12-15

MPL 515

¨ JAK2 Exon 12-15 Mutation

¨ MPL 515 Mutation

¨ CALR Mutation

¨ KIT D816V Mutation Digital PCR

¨ Other Molecular, specify: ____________________________________________________

SPECIAL CHEMISTRY

(Serum ONLY)

Multiple Myeloma Diagnostic: *Meets IMWG Guidelines

¨ 120256 Immunofixation (sIFE), Protein Electrophoresis (SPE), Quant Free Ƙ/ƛ Light Chains (sFLC)*

¨ 123200 Mutiple Myeloma Cascade, SPE Reflex to sIFE and sFLC

Multiple Myeloma Monitoring:

¨ 001495 sIFE, SPE ¨ 001487 SPE ¨ 001685 sIFE

¨ 123218 sIFE DARZALEX

(daratumumab patients ONLY) ¨

123062 sIFE SARCLISA

(isatuximab patients ONLY)

¨ 121137 sFLC, Quantitative Free Light Ƙ/ƛ Chains plus Ratio

¨ Comprehensive Evaluation: Morphologic evaluation, Flow Cytometry,

Cytogenetics, and Other Relevant Diagnostic and/or Prognostic Tests per Opinion

of Reviewing Pathologist (see reverse for prognostic reflex criteria)

¨ Comprehensive Evaluation as above without Cytogenetics

Send to TN

Send to CT

Disease State Profiles (see reverse for panel components)

¨ ABC Lymphoma ¨ ALL (Adult) ¨ ALL (Pediatric) ¨ AML ¨ CLL

¨ Multiple Myeloma ¨ MPN/CML ¨ MPN w/ Eosinophilia ¨ MDS

Pediatric (COG)

¨ ALL (Std Risk) ¨ ALL (High Risk) ¨ AML

COG Single Probes

¨ ABL1 ¨ ABL2 ¨ PDGFRb

Individual Probes (for a complete list of probes visit oncology.labcorp.com)

¨ 5q ¨ ALK ¨ BCR/ABL1

¨ BCR/ABL1, if neg reflex to JAK2 V617F Qual, If JAK2 neg reflex to CALR and MPL

¨ CCND1/IGH, t(11;14) ¨ IGH/BCL2, t(14;18) ¨ IGH/MYC, t(8;14)

¨ KM2TA (MLL) ¨ PML/RARA ¨ RUNX1/RUNX1T1, t(8;21) ¨ TCRA/D

¨ TP53 (17p-)

Other FISH, specify: _______________________________________

Reveal

SNP Microarrayᵜ

If suspect balanced translocations, run cytogenetics and/or FISH

¨ SNP Microarray for ALL, AML, CLL, MDS and other Hematologic Malignancies

Indication: __________________________________________________________________

¨ FISH + SNP Microarray for Multiple Myeloma ¨ SNP Microarray for Multiple Myeloma

If MM (FISH+SNP) is ordered, probes t(4; 14), t(11; 14), t(14; 16) are performed

Name

8310075583

HEMATOLOGY/ONCOLOGY

oncology.labcorp.com

Highlighted fields are REQUIRED

Client Services

TN: (800) 874-8532 fax: (615) 370-8074

AZ: (800) 710-1800 fax: (800) 481-4151

Client#

Client Name

Address

Phone Number

Fax Number

Lab Locations

Accupath Diagnostic Laboratories, Inc. Esoterix Genetic Laboratories, LLC

201 Summit View Drive, Suite 100

Brentwood, TN 37027

5005 South 40th Street

Phoenix, AZ 85040

3 Forest Parkway

Shelton, CT 06484

Darzalex

is a registered trademark of Johnson & Johnson Corporation.

LeukoStrat

is a registered trademark of Invivoscribe Technologies, Inc.

SARCLISA

is a registered trademark of Sanofi.

Accupath Diagnostic Laboratories, Inc. and Esoterix Genetic Laboratories, LLC are subsidiaries of Laboratory Corporation of America Holdings, using the brand Labcorp and Labcorp Oncology.

onc-711-v25 06072022

Flow Cytometry

Peripheral blood/bone marrow panel (HNA)

antibodies

CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD13, CD14,

CD16, CD19, CD20, CD23, CD57, CD33, CD34, CD38, CD45,

CD56, CD64, HLA-DR, kappa light chain, lambda light chain

Tissue/fluids panel (HNA)

antibodies

CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD19, CD20,

CD23, CD30, CD38, CD43, CD45, CD56, CD57, FMC-7,

HLA-DR, kappa light chain, lambda light chain

PNH Evaluation

CD14, CD15, CD24, CD45, CD64, FLAER.

CD59 and CD235a may be added at discretion of reviewing

pathologist

Additional antibodies may be added if determined to be medically necessary to render a diagnosis in the opinion of the reviewing pathologist.

Markers performed determined by testing facility.

FISH

(disease state profile OR individual probes)

ALL (Adult)

BCR/ABL1, t(9;22)

KMT2A (MLL)

MYC

21q

ALL (Pediatric)

BCR/ABL1,t(9;22)

KMT2A (MLL)

CDKN2A (p16)

TCF3 (E2A)

ETV6/RUNX1, t(12;21)

AML

PML/RARA, t(15;17)

CBFB, inv(16)

RUNX1T1/RUNX1, t(8;21)

KMT2A (MLL)

CLL

TP53 (17p-)

ATM (11q-)

CCND1/IGH, t(11;14)

13q14 (DLEU)

MPN/CML

20q

13q14 (DLEU)

BCR/ABL1, t(9;22)

Multiple Myeloma

Monosomy 13/13q-

TP53 (17p-)

CCND1/IGH, t(11;14)

CKS1B (1q21)

FGFR3/IGH, t(4;14)

IGH/MAF, t(14;16)

NHL

ALK

BCL6

CCND1/IGH, t(11;14)

IGH/BCL2, t(14;18)

IGH/MYC, t(8;14)

MALT1

TCRA/D

Aggressive B-cell (ABC) Lymphoma

BCL2

BCL6

MYC

MDS

20q

MPN with Eosinophilia

FGFR1

PDGFRA

PDGFRB

Morphologic Evaluation Common Components (Please include patient CBC report)

• Peripheral Blood Interpretation (85060) • Clot (88305)

• Bone Marrow Aspirate Smear & Interpretation (85097)

• Core (88305)

• Decalciﬁ cation (88311)

• Additional Studies/Special Stains (88313) – Iron and Reticulin

• IHC Global marker number (88342) varies but typically 0-4

Diagnostic Test Reflex Criteria Based on Flow Cytometry or Surgical Pathology Consultation Findings

Disease Category Timing Findings Tests to Perform

AML

Initial Diagnosis Diagnostic or suspicious for AML with RUNX1T1/RUNX1 t(8;21), CBFB inv (16),

or PML/RARA t(15;17), acute myelomonocytic, or acute monocytic/monoblastic

leukemia

FISH probes for RUNX1T1/RUNX1 t(8;21), CBFB inv(16), or PML/

RARA t(15;17) or MLL respectively, as indicated; NGS myeloid panel

+ FLT3 testing for patients <60 years; discuss necessity of testing with

client or place comment in report for patients >= 60 years

B-cell lymphoma

Initial Diagnosis

Findings suspicious or diagnostic for B-cell lymphoma, but with equivocal ﬁ ndings

with regard to subclassiﬁ cation (for tissue cases 5% or more abnormal B-cells by ﬂ ow

cytometry; for peripheral blood/bone marrow cases, 10% or more abnormal B-cells)

NHL FISH probes and molecular assays as indicated

Large B-cell lymphoma or

Burkitt lymphoma

Initial Diagnosis Abnormal B-cells diagnostic or suspicious for large B-cell lymphoma or Burkitt

lymphoma

FISH probes for MYC, BCL6, and BCL2 translocations and cytogenetic

karyotyping, as indicated; reﬂ ex to 11q FISH probe (BCL1 and

ATM) for MYC, BCL6, BCL2 negative cases suspicious for Burkitt

lymphoma, as indicated

Eosinophilia

Initial Diagnosis Peripheral blood with 1.0K/µL or more eosinophils FISH probes for PDGFRA, PDGFRB, and FGFR1

Hairy Cell Leukemia (HCL)

Initial Diagnosis CD103+ monoclonal B-cells (5% or more) inconclusive for HCL BRAF mutation

Lymphoplasmacytic

Lymphoma (LPL)

Initial Diagnosis Monoclonal B-cells (10% or more) with features indicating LPL in

differential diagnosis

MYD88 mutation

Mantle cell lymphoma (MCL)

Initial Diagnosis Monotypic B-cells (5% or more) diagnostic or suspicious of MCL FISH probe for CCND1/IGH t(11;14)

Mastocytosis

Initial Diagnosis Atypical mast cells by ﬂ ow cytometry High-sensitivity KIT D816V mutation analysis for mast cell disease

CML

Initial Diagnosis Flow cytometric findings suspicious for CML FISH for BCR/ABL1

MDS/MPN

Initial Diagnosis Findings suspicious for MDS/MPN (CMML, aCML, etc.) NGS myeloid panel for patients <60 years; discuss necessity of

testing with client or place comment in report for patients >= 60 years

T-cell lymphoma/leukemia

Initial Diagnosis Atypical T-cells diagnostic or suspicious for T-cell lymphoma/leukemia TCR gene rearrangement ; ALK FISH probe for CD30+ cases, as

indicated; cytogenetic karyotyping if material adequate

LeukoStrat

CDx FLT3 Mutation performed by The Laboratory for Personalized Molecular Medicine (LabPMM

)

‡

Informed consent is required for non-oncology genetics testing for New York state patients.

IntelliGEN

(for genes evaluated, refer to oncology.labcorp.com)

Prognostic Test Reflex Criteria

Disease Category Timing Findings (Morphology, Flow cytometry, FISH and/or karyotyping) Tests to Perform

ALL

Initial Diagnosis ALL Pediatric FISH Proﬁ le (<22 years) or Adult FISH Proﬁ le (>22

years); Reveal

SNP Array

AML

Initial Diagnosis AML or borderline AML FISH probes for RUNX1T1/RUNX1 t(8;21), CBFB inv(16), or PML/

RARA t(15;17) or MLL respectively, as indicated; NGS myeloid panel

+ FLT3 testing for patients <60 years; discuss necessity of testing

with client or place comment in report for patients >= 60 years

AML

Relapse Findings indicative of relapse NGS myeloid panel <60 years; discuss necessity of testing with

client or place comment in report for patients >= 60 years

CLL (peripheral blood/bone

marrow)

Initial Diagnosis CD5+ neoplasm with classic or variant CLL features; >5K/uL circulating

monoclonal B-cells or 10% or more marrow based monoclonal B-cells

CLL FISH proﬁ le or CLL SNP array with FISH probe for CCND1/IGH

t(11;14), ZAP70/CD38/CD49d assay, and IgVH mutation analysis

CLL (peripheral blood/bone

marrow)

Follow-up* Features of refractory disease or disease progression/transformation FISH probe for TP53 (17p-) deletion, TP53 mutation analysis, and

SNP array

CML

Initial Diagnosis Compatible or diagnostic ﬁ ndings for CML Quantitative BCR/ABL1 assay and cytogenetics

CML

Follow-up* Prior diagnosis of CML Quantitative BCR/ABL1 assay; if features of progression, discuss

addition of NGS myeloid panel with client or place comment in report

MPN

Initial Diagnosis Morphologic features of MPN, but negative for JAK2 V617F, CALR, and MPL

mutations

NGS myeloid panel for patients <60 years; discuss necessity of

testing with client or place comment in report for patients >= 60 years

MPN

Follow-up* History of MPN, currently with features of progression (increased blasts or

dysplastic features)

Discuss addition of NGS myeloid panel with client or place comment

in report

MDS

Initial Diagnosis Morphologic diagnosis of MDS with normal cytogenetic karyotype NGS myeloid panel for patients <60 years; discuss necessity of

testing with client or place comment in report for patients >= 60 years

Plasma cell neoplasia

Initial Diagnosis 5% or more neoplastic plasma cells by morphology or 1% or more

by ﬂ ow cytometry

Myeloma FISH proﬁ le

Plasma cell neoplasia

Follow-up* Features of disease progression FISH probes for TP53 (17p-), CKS1B (1q21), Monosomy 13/13q-

SLL

Initial Diagnosis SLL identiﬁ ed in tissue sample by ﬂ ow cytometry with 10% or more

neoplastic cells

CLL FISH proﬁ le or CLL SNP array with FISH probe for CCND1/IGH

t(11;14), IgVH mutation analysis

*recommendation for follow-up evaluation requires that prior material was evaluated in an IO facility

SERUM - Multiple Myeloma Cascade, Protein Electrophoresis (SPE) reflex to Immunofixation (sIFE) and Free Light Chain (sFLC)

for interpretation, refer to www.labcorp.com

B2A

8310075583

Patient, client, and billing information is requested for timely

processing of this case. Medicare and other third party payors

require that services be medically necessary for coverage,

and generally do not cover routine screening tests.

When ordering tests that are subject to ABN guidelines,

Administrative Contractor (MAC), CMS, or

Symbols Legend

@ = Subject to Medicare medical necessity guidelines

^ = Medicare deems investigational. Medicare does not pay for services it deems investigational.

refer to the policies published by your Medicare