Ancillary Testing Requisition

Ordering Location
Ordering Location*
Ordering Physician*
Patient Information
Name*
First MI Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Gender*
- Male
- Female
MRN#
Accession#
Billing Information
Billing Information
- Technical
- Global
- Client Bill
- Insurance /Patient (Copy of insurance card required)
- Hospital (In/out patient at time of procedure)
- Hospital (Medicare)
- Non - Hospital (Outreach/Clinic patient)
Specimen Information
Specimen Information*
- Block(s)
- Slide(s)
- Other
Block(s) ID#
Slide(s) ID#
Special Comments
Collection Date
Date Format: MM slash DD slash YYYY
Specimen Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Time in Formalin
Time out of Formalin
ICD10 Code(s)
Requested Testing
Immunostains
- Actin-Muscle specific (HHF35)
- Adipophilin
- ALK-1 (ALK01)
- Arginase 1 (SP156)
- BAP-1 (C-4)
- BCL-2 (124)
- BCL-6 (GL191E/A8)
- BerEP4
- Beta Catenin (14)
- BRAF (V600E)
- Calretinin (Poly)
- CAIX (MRQ-54)
- CAM5.2 (CAM5.2)
- CD1a (010)
- CD2 (AB75)
- CD3 (2GV6)
- CD4 (SP35)
- CD5 (SP19)
- CD7 (LP-15)
- CD8 (C8/144B)
- CD10 (56C6)
- CD15 (LeuM1)
- CD19 (BT51E)
- CD20 (L26)
- CD23 (SP23)
- CD30 (Ber-H2)
- CD31 (1A10)
- CD33 (PWS44)
- CD34 (QBEnd/10)
- CD43 (L60)
- CD45 (RP2/18)
- CD56 (123C3)
- CD68 (KP-1)
- CD79a (11E3)
- CD117 (YR145)
- CD138 (B-A38)
- CD163 (MRQ-26)
- CDX2 (EPR2764Y)
- CEA (TF 3H8-1)
- Chromogranin (LK2H10)
- CK (Pan)(AE1/AE3)
- CK5/6 (D5/16B4)
- CK7 (OV-TL 12/30)
- CK8/18 (B22.1/B23.1)
- CK20 (SP33)
- CK34 (betaE12)
- Claudin-4 (3E2C1)
- CMV (DD59/CCH2)
- C-Myc (EP121)
- Cyclin D1 (SP4)
- D2-40 (Podoplanin)
- Desmin (D E-R-11)
- DOG-1 (SP31)
- E-Cadherin (36)
- EMA (E29)
- ER (qualitative) (6F11)
- ERG (9FY)
- Factor-13a (EP3372)
- Fascin (55-K2)
- Gastrin-Send Out
- GATA-3 (L50 - 823)
- GCDFP-15 (23A3)
- GFAP (G-A-5)
- H. Pylori (Poly)
- Hemoglobin A (EPR3608)
- Hepar-1 (OCH1E5)
- HER2neu (4B5)
- HHV8 (13B10)
- HMB45 (HMB45)
- HSV1 & 2 Cocktail (Poly)
- IDH1 (R132H)
- Inhibin (R1)
- INSM1 (A-8)
- Ki-67 (K2)
- Mammaglobin (31A5)
- Mart-1/Melan A (A103)
- MITF-1 (C5/D5)
- MOC-31 (MOC-31)
- MUM-1 (BC5)
- Myeloperoxidase (MPO-7)
- Napsin (IP64)
- NKX3.1 (Poly)
- Oct-2 (MRQ-2)
- OSCAR (OSCAR)
- P16 (P16ink4a)
- P40 (BC28)
- P504s Only (AMACR)
- P53 (D0-7)
- P57 (KIP2)
- P63 (4A4)
- P120 (MRQ-5)
- PAX-5 (1EW)
- PAX-8 (MRQ-50)
- PD1 (MRQ-22)
- PR (qualitative) (16)
- PSA (35H9)
- PSAP (PASE/4LJ)
- ROS-1 (D4D6)
- S-100 (Poly)
- SMM-heavy chain (SMMS-1)
- Smooth Muscle Actin (IA4)
- SOX-10 (EP268)
- SOX-11 (C1)
- Spirochete (Poly)
- Synaptophysin (27612)
- TTF-1 (8G7G3/1)
- Vimentin (V9)
- WT-1 (WT49)
Special Stains
- AB/PAS (Alcian Blue)
- AFB
- Colloidal Iron
- Colloidal Iron w/Kidney
- Control
- Congo Red
- Diff Quik
- Elastic
- Fite
- Giemsa
- Gomori's Meth Silver
- Gram (B&B)
- Iron
- Masson's Trichrome
- Mayer's Mucicarmine
- PAS Fungus
- PAS w/wo Diatase
- PAS/Basement
- Retic
- Other
Multiplex Stains
- p16/Ki-67P16-DAB Chromogen (Brown) KI-67–Alk Phos Chromogen (Red)
- KI-67/CK (pan) KI-67–DAB chromogen (Brown) CK (pan)–Alk Phos Chromogen(Red)
- Ki-67/MART-1Ki-67–DAB Chromogen (Brown) MART-1-Alk Phos Chromogen (Red)
- Ki-67/SYNAPTOPHYSIN KI-67–DAB Chromogen (Brown) SYNAPTO-Alk Phos Chromogen (Red)
- PAN/DES PanKeratin–DAB Chromogen (Brown) DESMIN–Alk Phos Chromogen (Red)
- PIN-4P63-DAB Chromogen (Nuclear–Brown) 34BE12-DAB Chromogen (Cytoplasm Red) P504s–Alk Phos Chromogen (Red)
- CK-ENDO PanKeratin–DAB Chromogen(Brown) CD34–Alk Phos Chromogen (Red) D2-40–Alk Phos Chromogen (Red)
- SYNAPTOPHYSIN/D2-40 Synapto–DAB chromogen (Brown) D2-40–Alk Phos Chromogen (Red)
Biomarkers Technical and Interpretation
- Breast Panel
- ER only
- ER/PR only
- ER/PR/Her2
- Her2neu IHC FDA
- Breast
- Gastric
- ER/PR/Her2-SMC-Tech Only
- BRAF–V600E–by IHC
- MMR proteins MSH6, MSH2, MLH1, PMS2
- ALK IHC (D5F3) CDx Assay XALKORI® (Crizotini)* FDA Approved
- PD-L1 IHC (22C3) PharmDx Assay KEYTRUDA® (Pembrolizumab)* FDA Approved
- PD-L1 IHC (28-8) PharmDx Assay OPDIVO® (nivolumab)* FDA Approved
- PD-L1 IHC (SP263) IMFINZI Assay IMFINZI® (durvalumab)* FDA Approved
ISH/Probes
- Albumin ISH
- EBER (EBV) ASR
- HPV 16,18, 31, 33
- Kappa ASR
- Lambda ASR
- Other

Ancillary Testing

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Requested Testing

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