Request Form

PRINT, SEND WITH SPECIMEN

HCMC Level 1 Trauma Center 701 Park Ave. Mpls, MN 55415	PLEASE REMEMBER TO: oRequest/ Mark test(s) oInclude Billing Information oSend Specimen appropriately	STAT CALL TO: FAX TO:
DATE COLLECTED:	TIME:	BILL TO: ACCOUNT COMMERCIAL INSURANCE: MEDICARE MEDICAID PATIENT
INSTITUTION: ADDRESS:
REFERRING PHYSICIAN:
Send Additional Copy to: Client or Physician name:
ADDRESS:
CITY:	STATE:	ZIP:
ICD9 DIAGNOSIS CODE(S) FOR TESTS ORDERED

PATIENT RESPONSIBLE PARTY SIGNATURE (SEE REVERSE SIDE FOR ACKNOWLEDGMENT STATEMENT:) I have read the Statement on the back of this requistion that Medicare is likely to deny payment for identified service(s) for the reason stated. If Medicare denies payment, I agree to be personally responsible for payment. X:

PATIENT NAME: (LAST, FIRST, MI):

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE #

DATE OF BIRTH:

SEX:

OFFICE/CHART ID#:

PATIENT SOCIAL SECURITY #:

HCMC MEDICAL RECORD # (IF AVAILABLE):

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INSURANCE COMPANY NAME:
MEMBER INSURED ID#:		GROUP NUMBER:
INSURANCE ADDRESS:
CITY	STATE:	ZIP:
EMPLOYER NAME:
MEDICARE #:
MEDICAID #:		STATE IF NOT MN:

DIAGNOSIS:

PRENATAL TESTING 612-347-3003

CYTOGENETICS 612-347-8548

ALPHA-FETOPROTEIN

Maternal Serum

Amniotic Fluid

DOUBLE SCREEN (AFP and BHCG)
TRIPLE SCREEN (AFP, BHCG, UE3)
FETAL LUNG MATURITY (FLM)
ACETYLCHOLINESTERASE

(Please fill out the following information when ordering the above tests)

Date of sample collection: ____/_____/_______

Gestation age:______________as of ______/______/______
Determined by:

Race:

Europe American
African American
Asian American

Hispanic
Native American
Other__________

Indication:

Routine
Repeat (previous abnormal AFP)
Family Hx of NTD

Family HX Down Syndrome
Advanced Maternal AgeOther:_______________

AMNIOTIC FLUID CHROMOSOME STUDY

Gestation age:________as of ______/______/______

BONE MARROW CHROMOSOME STUDY
HEMATOLOGIC BLOOD CHROMOSOME STUDY
WBC:___________________

MALIGNANT TISSUE CHROMOSOME STUDY
Source:_______________________

BLOOD CHROMOSOME STUDY

Metaphase Bands
Prometaphase Bands (High Resolution)
Fragile X Molecular Study

PRODUCTS OF CONCEPTION/ ABORTUS/ FETAL TISSUE CHROMOSOME STUDY

SKIN BIOPSY FOR CHROMOSOME STUDY

FISH (Fluorescent in situ Hybridization)

OTHER:

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