Cardiovascular Pharmacogenomics Requisition FormCT-ST License # CL 05D1092505

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1. Patient Information

PATIENT Last NAME: First name: M.I.: SEX:

(Street)Patient Address: City: State: ZIP:

PATIENT PHONE # Patient Email: (MM/DD/YY)Date of birth:

(Check all that apply)Ethnicity:

Date and Time Collected: SWAB COLLECTED BY:

POLICY HOLDER NAME: (MM/DD/YY)POLICY HOLDER Date of birth:

Insurance Company Name: Member / Policy # GROUP # RELATIONSHIP OF PATIENT TO INSURED:

(IF APPLICABLE)MEDICARE/MED. NUMBER: State:

2. Ordering Provider

Ordering Physician Name: NPI # Signature:

(MM/DD/YY)Date: Phone # Fax #

Address:

3. ICD-10 Code(s) For Tests Ordered (See Section 13)must be provided

Primary Dx1: Secondary Dx2: Dx3: Dx4:

CPT Codes Required Clinical Information

4. Specimen type 5. Test ProvidedPlease check

info@omecare.com6777 Nancy Ridge Drive, San Diego, CATel: 858-771-0541 • Fax: 858-866-8505 • Email:

Male Female

Self Spouse Dependent

African-American

Asian

Caucasian / NW European

E. Indian

Hispanic

Mediterranean

Jewish-Ashkenazi

Jewish-Sephardic

Native American

Other:

Medical Necessity Statement: Tests ordered on Medicare patients must follow CMS rules regarding medical necessity and FDA approval guidelines and must

include diagnosis, symptoms and reason for testing as indicated in the medical record. If testing does not come under Medicare guidelines for payment a ‘signed’

Advanced Beneficiary Notice must be included.

Physicians must provide all of the following for medical necessity:

0173U

0175U

81479

Medical notes documenting all the following:

• Diagnosis

• History of illness, including treatments tried and failed

• Genes included in Panel

• Name of lab performing test and name of test, if available

• Physician treatment plan based on results of genetic testing

Pharmacogenetic Testing

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Buccal swabCardiovascular Pane: (CYP2C19, CYP2D6, CYP2C9, VKORC1,CYP3A4, CYP3A5, Factor II, Factor V, MTHFR, APOE, SLCO1B1)

6. To CliniciansRequired.Establish medically necessity for referral; document clinical utility of tests.

7. Medication lists, clinical notes on Adverse drug reactions or inefficacy should be attachedWhat clinical characteristics of this Patient warrant referral for pharmacogenetic testing? Please check.

8. How will pharmacogenetic results directly change treatment or management of this Patient?Please check.

Current Medication(s):

Intended Medication(s):

9. Patient billing informationPlease include a copy of drivers license and insurance card(s) both front and back for billing pupposes.

10. Patient authorization

RequiredSignature of Patient/Responsible Party: Required(MM/DD/YY) Date:

11. Specimen collection instructions

Specimen Type:

Buccal (cheek) swabVolume:

1 swabContainer:

5ml tube (accompanies swab)Storage Conditions:

Room temperatureSpecial Instructions:

Do not freeze

12. specimen shipping instructions – federal express shipping instructions

Client bill Insurance Medicare / Medicaid Self pay

I understand that I am responsible for providing accurate information about my insurance to Ome Ventures Inc.  I understand that Ome Ventures Inc.will be providing testing service and billing my insurance. However, I understand that charges that are not covered by my insurance, including any applicable copayments and deductibles are my responsibility and I agree to pay such charges promptly.

www.fedex.com

Use sterile technique for specimen collection and close all containers tightly. DO NOT FREEZE OR ADD FIXATIVE TO ANY SAMPLE. Each specimen must be clearly labeled with at least two patient identifiers (patient’s name and date of birth), along with the collection date. Secure each specimen container tightly to avoid leakage in transit.

Complete the test requisition with the patient’s demographics and insurance information. There is a secondary pouch in the biohazard bag for the test requisition. The clinical indication is required for appropriate cell culture parameters.

Place the specimen in the absorbent material inside the enclosed biohazard bag. Then place the biohazard bag into the insulated specimen box labeled “Biohazardous Material” “Exempt Human Specimen”. Please package the specimen carefully to protect it from breakage, leakage, and extreme temperatures. Place the specimen box inside the enclosed FedEx Clinical Pak (lab shipping bag) and seal.

Attach the pre-labeled and prepaid FedEx air bill. You can call FedEx at (800) 463-3339 to schedule a FedEx pickup. Alternately, a pick-up can be scheduled online at . A two-hour notice may be required for same-day pick-up. Delivery address: 6777 Nancy Ridge Drive, San Diego, CA., 92121, via FedEx overnight.

Contact Laboratory for additional shipping materials, further instructions or any questions: 858 771 0541.

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I1.0 Hypertension

I25.2 Old myocardial infarction

I70.0 Aortic Athlerosclerosis

Other:

Drug intolerance and side effects

Treatment resistance and lack of efficacy

Multiple medical conditions or hospitalization

Treatment with multiple medications

Elderly or infirm vulnerable patient

Family history of drug side effects

Hypercoagulable state (contraceptives, lupus)

Selection of new prescription medication(s)

Alternative dosing of existing medication(s)

Discontinuation of existing medication(s)

Adjustment of current multi-drug regimen

Clarification of prior equivocal diagnostics

info@omecare.com6777 Nancy Ridge Drive, San Diego, CATel: 858-771-0541 • Fax: 858-866-8505 • Email:

13. diagnosis /indication. check all iCD-10 codes that applyThis list is supplied as a courtesy and is not a complete list. Provider should use the most appropriate diagnosis based on the patient indications.

d68.9 Coagulation defect, unspecified

I1.0 Hypertension, NOS

I20.0 Intermediate coronary syndrome

I20.1 Prinzmetal angina

I20.8 Amgina decubitus

I21.3 Acute myocardial infarction, NOS, unspecified

I20.9 Angina pectoris, NEC/NOS

I21.4 Subendocardial infarction, unspecified

I21.09 Acute myocardial infarction of anterolateral, unspecified

I21.09 Acute myocardial infarction of anterolateral wall, unspecified

I21.11 Acute myocardial infarction of inferoposterior, unspecified

I21.19 Acute myocardial infarction of inferolateral, unspecified

I21.19 Acute myocardial infarction of inferolateral wall, unspecified

I21.29 Acute myocardial infarction of lateral, NEC, unspecified

I21.29 True posterior infarction, unspecified

I21.29 Acute myocardial infarction, NEC, unspecified

I24.0 Acute coronary occlusion without myocardial infarction

I24.1 Postmyocardial infarction syndrome

I24.9 Acute ischemic heart disease, NEC

I25.2 Old myocardial infarction

I25.10 Coronary atherosclerosis of unspecified type of vessel, native or graft

I25.10 Coronary atherosclerosis of native coronary artery

I26.99 Other pulmonary embolism and infarction

I27.82 Chronic pulmonary embolism

I42.9 Secondary cardiomyopathy, NOS

I48.91 Atrial brillation

I49.01 Ventricular brillation

I50.9 Congestive heart failure, unspecified

I50.22 Chronic systolic heart failure

I50.32 Chronic diastolic heart failure

I50.42 Chronic combined systolic and diastolic heart failure

I65.29 Occlusion and stenosis of carotid artery without mentionof cerebral infarction

I67.1 Nonruptured cerebral aneurysm

I70.0 Atherosclerosis of aorta

I70.25 Atherosclerosis of native arteries of other extremities with ulceration

I73.00 Raynaud's syndrome

I73.9 Peripheral vascular disease, unspecified

I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity

I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity

I82.509 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity

I82.629 Acute embolism and thrombosis of deep veinsof unspecified upper extremity

I82.729 Chronic embolism and thrombosis of deep veinsof unspecified upper extremity

info@omecare.com6777 Nancy Ridge Drive, San Diego, CATel: 858-771-0541 • Fax: 858-866-8505 • Email: