Buccal Swab Sample

(MM/DD/YYYY)______/______/________ ____:____AM / PM

Pa�ent Last Name

Pa�ent First Name Street Address

City State Zip Code Date of Birth (MM/DD/YY)

Gender Height Weight

Office Contact Office Email / Phone # Physician NPI#

PHARMACOGENETIC (PGx)

Male Female

White Asian Other/Unknown Mixed Race Hawaiian/Pacific Islander Black

ICD-10 Codes (SEE BACK and please list all applicable codes)

Physician Authorizing Name Physician Authorizing Signature

Name Signature

AND include photocopy of both sides of insurance card or face sheet

_______________________________ ______________________________ _______________________________ ______________________________

_______________________________ ______________________________ _______________________________ ______________________________

_______/_______/_________

_______/_______/__________

Primary Insurance ID Number Group Number

Name of Person Insured Date of Birth (MM/DD/YY)

indis

Medical Necessity:

There is a “Warning” “Controlled Substance”.

An “Inhibitor” or “Inducer”

A component of my medical decision making for which

A component of my medical decision making as to which

A component of my medical decision making regarding dose

A component of my medical decision making to manage’

Provider Notes:

PLEASE CHECK ALL THAT APPLY:

PGx Panel ANKK1 (DRD2), ApoE, CYP2C19, CYP2B6, CYP2C9, CYP2D6 , CYP3A4, CYP3A5, Factor II, Factor V, G6PD, HFE, IFNL3 (IL28B), IL6, ITGB3, LPA, MTHFR, OPRM1, OPRD1, TPMT, SLCO1B1, UGT2B15, VKORC1

I request and authorize CoreBioLabs to perform the designated test(s) on the sample provided by me. My signature below cons�tutes my acknowledgment that I have been informed of the benefits and limita�ons of this tes�ng which have been explained to my sa�sfac�on by a qualified health professional. Assignment of Benefits: I hereby authorize CoreBioLabs or its affiliate to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with its collec�on. I hereby authorize my insurance company to pay the company directly for services rendered. Appeal Authoriza�on: In the event of an underpayment or denial by my insurance carrier, I hereby authorize the company or their designee, to appeal my health plan on my behalf to provide the ac�ons and informa�on necessary to overturn the denial or receive reimbursement for the underpaid claim. This authoriza�on shall remain valid un�l the charges for the orders on this form are paid in full. Donor Signature: I cer�fy that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen used was sealed in my presence; and that the informa�on provided on this form and on the label affixed to each specimen is correct. I authorize the release of the results to the ordering clinician, authorized client/representa�ve, or prescribing/a�ending physician. I authorize CoreBioLabs or its affiliates to release any informa�on required for billing purposes. I acknowledge CoreBioLabs or its affiliates may be an out of network provider with my insurer. I also agree that in a case where my insurance provider sends payment directly to me, I will endorse the insurance check and forward to CoreBioLabs within 30 days.

CoreBioLabs • 8285 Darrow Rd. #101, Twinsburg, OH 44087 • Phone: (330) 405-2623 • Fax: (330) 405-0859 Web: www.corebiolabs.com • E-mail: info@corebiolabs.com • CLIA# 36D2061372 • CAP# 7541618 Revision 1.2, August 2019

ST Elevation (STEMI) Myocardial Infarction Involving:( ) I21.09 other coronary artery of anterior wall( ) I21.11 right coronary artery( ) I21.19 other coronary artery of inferior wall( ) I21.29 other sites( ) I21.3 unspecified site

( ) I21.4 Non-ST elevation (NSTEMI) myocardial infarction

Atherosclerotic Heart Disease of Native Coronary Artery:( ) I25.10 without angina pectoris( ) I25.110 with unstable angina pectoris( ) I25.111 with angina pectoris w documented spasm( ) I25.118 with other forms of angina pectoris

Atherosclerosis of Autologous Vein Coronary Artery Bypass Graft(s):( ) I25.71 with angina pectoris w documented spasm( ) I25.710 with unstable angina pectoris( ) I25.711 with angina pectoris w documented spasm( ) I25.718 with other forms of angina pectoris( ) I25.719 with unspecified angina pectoris

Atherosclerosis of Autologous Artery Coronary Artery Bypass Graft(s):( ) I25.720 with unstable angina pectoris( ) I25.721 with angina pectoris w documented spasm( ) 125.728 with other forms of angina pectoris

Atherosclerosis of Nonautologous Biological Coronary Artery Bypass Graft(s):( ) I25.731 with angina pectoris w documented spasm( ) I25.738 with other forms of angina pectoris( ) I25.739 with unspecified angina pectoris

Atherosclerosis of Native Coronary Artery of Transplanted Heart:( ) I25.750 with unstable angina( ) I25.751 with angina pectoris w documented spasm( ) I25.758 with other forms of angina pectoris( ) I25.811 without angina pectoris

Atherosclerosis of Bypass Graft of Coronary Artery of Transplanted Heart:( ) I25.60 with unstable angina( ) I25.761 angina pectoris with documented spasm( ) I25.768 other forms of angina pectoris( ) I25.769 with unspecified angina pectoris( ) I25.812 without angina pectoris

Atherosclerosis of Other Coronary Artery Bypass Graft(s):( ) I25.700 unspecified, with unstable angina pectoris( ) I25.708 unspecified, with other forms of angina pectoris( ) I25.709 unspecified, with unspecified angina pectoris( ) I25.730 nonautologous with unstable angina pectoris( ) I25.790 unstable with angina pectoris( ) I25.791 angina pectoris with documented spasm( ) I25.798 other forms of angina pectoris

Additional Cardiovascular:( ) D68.2 Hereditary deficiency of other clotting factors( ) I10 Essential (primary) hypertension( ) I20.0 Unstable angina( ) I20.1 Angina pectoris w documented spasm( ) I20.8 Other forms of angina pectoris( ) I20.9 Angina pectoris, unspecified( ) I21.9 Acute myocardial infarction, unspecified( ) I21.A1 Myocardial infarction type 2( ) I21.A9 Other myocardial infarction type( ) I24.0 Acute coronary thrombosis not resulting in myocardial infarction( ) I24.1 Dressler's syndrome( ) I24.8 Other forms of acute ischemic heart disease( ) I24.9 Acute ischemic heart disease, unspecified( ) I25.5 Ischemic cardiomyopathy( ) I25.6 Silent myocardial ischemia( ) I25.810 Atherosclerosis of coronary artery bypass graft(s) w/o angina pectoris( ) I25.83 Coronary atherosclerosis due to lipid rich plaque( ) I25.84 Coronary atherosclerosis due to calcified coronary lesion( ) I25.89 Other forms of chronic ischemic heart disease( ) I25.9 Chronic ischemic heart disease, unspecified( ) I48.91 Unspecified atrial fibrillation( ) I50.9 Heart failure, unspecified( ) I82.91 Chronic embolism and thrombosis, unspecified vein( ) R03.0 Elvtd blood pressure read, w/o diag of hypertension( ) Z79.01 Longterm (current) use of anticoagulants

Please insure that all ICD-10 codes checked on the Requisition Form are representative of the patient being seen and their health considerations. For a comprehensive listing please refer to the most recent ICD-10 coding manual. Ultimately the assignment of the proper diagnosis code(s) is the responsibility of the ordering physician.

CARDIOVASCULAR

Major Depressive Affective Disorder Recurrent Episode( ) F32.9 Major depressive disorder, single episode, unspecified ( ) F33.9 Unspecified( ) F33.0 Mild( ) F33.1 Moderate( ) F33.2 Severe without psychotic features( ) F33.3 Severe with psychotic features( ) F33.40 In remission upspecified( ) F33.41 In partial remission( ) F33.42 In full remission

Bipolar I Disorder Most Recent Episode (or Current) DEPRESSED ( ) F31.30 Unspecified ( ) F31.31 Mild( ) F31.32 Moderate ( ) F31.4 Severe w/o psychotic features( ) F31.5 Severe, w/psychotic features ( ) F31.75 In partial remission ( ) F31.76 In full remission

Bipolar I Disorder, Most Recent Episode (or Current) MIXED( ) F31.60 Unspecified( ) F31.61 Mild( ) F31.62 Moderate( ) F31.63 Severe, w/o psychotic features( ) F31.64 Severe, w psychotic features( ) F31.77 In partial remission( ) F31.78 In full remission( ) F32.89 Other specified depressive episodes( ) F31.9 Bipolar disorder, unspecified

( ) F41.9 Anxiety disorder, unspecified( ) F90.9 Attention deficit hyperactivity disorder, unspecified

ENDOCRINE

( ) G89.4 Chronic pain syndrome( ) M12.9 Arthropathy, unspecified( ) M15.9 Polyosteoarthritis, unspecified( ) M25.50 Pain in unspecified joint( ) M25.569 Pain in unspecified knee( ) M54.5 Low back pain( ) M60.9 Myositis, unspecified( ) M79.1 Myalgia( ) M79.609 Pain in unspecified limb( ) M79.7 Fibromyalgia( ) Z79.891 Longterm (current) use of opiate analgesic( ) Z79.899 Other longterm (current) drug therapy

( ) E03.9 Hypothyroidism, unspecified( ) E10.9 Diabetes I mellitus, w/o complications( ) E11.9 Diabetes II mellitus, w/o complications

MENTAL PAIN OTHER

( ) C20 Malignant neoplasm of rectum( ) C34.10 Malignant neoplasm of upper lobe, unspec. bronchus, lung ( ) C50.911 Malignant neoplasm of unspec. site of right female breast ( ) C61 Malignant neoplasm of prostate( ) C91.10 Chronic lymphocytic leuk of B-cell type not achieve remis ( ) E01.0 Iodine-deficiency related diffuse (endemic) goiter( ) E04.0 Nontoxic diffuse goiter( ) E04.1 Nontoxic single thyroid nodule( ) E04.2 Nontoxic multinodular goiter( ) E04.9 Nontoxic goiter, unspecified( ) G10 Huntington's disease( ) I66.8 Occlusion and stenosis of other cerebral arteries( ) N40.0 Benign prostatic hyperplasia w/o lower urinary tract symp ( ) N40.1 Benign prostatic hyperplasia w lower urinary tract symp( ) Z79.02 Longterm (current) use of antithrombotics/antiplatelets( ) R06.02 Shortness of breath( ) R11.2 Nausea w vomiting, unspecified( ) R51 Headache( ) Z13.6 Encounter for early screening of cardiovascular disorder