Place Patient Stamp Here
Vanderbilt Diagnostic Laboratory
4605 TVC. Nashville, TN 37232
MR #:
Name:
Hematopathology
Testing Form
Birthdate:
Clinical Indication (give diagnosis if known):
______________________________________________________
Location Code:_________
[__] VCH
Visit / Billing #:
[__]
Additonal History in Star Form
D&H Account:_____________________________
Clinical Trial Patient: [__] Yes [__] No
[__] TVC3
[__] Other
Z00.6
Clinical trial patient, SOC billed to insurance
Z75.5
Clinical trial patient, research billed to D&H
Clinical Trial Diagnosis Codes:
ICD-10 (to be applied to all testing below unless otherwise specified)
__ __ __ . __ __ __ __
Provider for Clinical Communications: ___________________________ Phone: ___________________________
[__]
[__]
[__]
Initial visit
[__]
Previously treated with ____________________
[__]
Untreated
Follow-up Visit
[__]
___days since most recent therapy with _______
Suspected Relapse/Progression
[__]
Reason Suspected _______________________
[__]
[__]
[__]
[__]
Pre-SCT
Post-SCT
Auto
Allo
[__]
[__]
_____ # Days/Months
_____First
_____Second
RIC/Mini
Full
Specimen Information: Date and Time Specimen collected ______/______/______
[__] a.m. [__] p.m.
Specimen Type: [__] Blood [__] Bone Marrow (specify site and side)______________ [__] Other (specify):___________________
[__] BME (1 biopsy and 1 aspirate)
[__] BBB (bilateral biopsy and aspirate)
[__] BA1 (aspirate only)
[__] BB1 (biopsy only)
_____________________________________
Location of Specimen:
For FISH Requests, select either the panel where appropriate or individual probes from the panel
Lab Code
#
Tube Color
Test
Bone Marrow Testing Panel (Pathologist will select appropriate ancillary tests, based upon review of morphology and clinical history )
Bone Marrow (Ordering physician to select ancillary testing below)
Lab Code
#
Tube Color
Test
ICD
Lab Code
#
Flow Cytometry
FCL
Flow cytometry, leukemia/lymphoma
Y
Other (Specify)
Y
B Cell Gene Rearrangement (PCR)
Acute Myeloid Leukemia (AML Panel)
t(8;21) (AML1-ETO)
821
DG
DG
APL
APL: t(15;17) (PML-RARA)
DG
LV
I16
inv(16) (MYH11-CBFB)
DG
11M
BC2
BCL-2 Gene Rearrangement
LV
RFL
Bone Marrow Engraftment
LV
Chr 11q23 (MLL)
DG
Myelodysplastic Syndrome (MDS Panel)
DG
TCC
T-Cell Receptor Gamma Chain (PCR)
LV
C5Q
Chr 5q
B2A
BCR-ABL (PCR) (P210)
LV
C7Q
Chr 7q
DG
JK2
JAK2 (V617F)
LV
C8C
Chr 8 (centromere)
DG
20Q
Chr 20q
DG
FLT
DG
FLT3 Internal Tandem Duplication
LV
NPM1
NPM1 4 bp insertion in the NPM1 gene
LV
CALR
CALR (Calreticulin)
LV
BCR-ABL P190
LV
11A
BCR-ABL 1 Mutation Analysis (send-out)
LV
12C
Chr 12 (centromere)
BRLI 37 Gene Heme Panel (send-out)
LV
MIR
Chr 13q14 (miR15-16)
DG
Other (Specify)
LV
P13
Chr 17p13 (p53)
DG
CST
Molecular Genetics: Infectious Agents
Cat Scratch DNA (PCR)
DG
FLL
HCQ
Hepatitis C RNA Quant (PCR)
LV
MAN
Mantle Cell Lymphoma: t(11;14)
DG
HNA
HIV RNA Viral Load (PCR)
LV
MZL
Marginal Zone Lymphoma: t(11;18)
DG
PVB
Parvovirus B-19 DNA Detection (PCR)
R
BUR
Burkitt Lymphoma: MYC breakapart
DG
ALK
ALCL: ALK breakapart
DG
OLP
Other Lymphoma: BCL6 breakapart
DG
BRP
RFT
Cytogenetics
CBO
Chromosome Bone Marrow
DG
Chronic Lymphocytic Leukemia (CLL) Panel
Chr 11q23 (ATM)
Plasma Cell Myeloma (PCM Panel)
Acute Lymphoblastic Leukemia (ALL Panel)
t(12;21) (TEL-AML1)
DG
DG
DG
DG
DG
MAN
t(11;14)(CCND1-IGH)
DG
DG
17C
Chr 17p13 (p53)
DG
DG
11M
Chr 11q23 (MLL)
DG
13C
Chr13q14(RB)
922
t(9;22) (BCR-ABL)
DG
414
t(4;14) (FGFR3-IGH)
119
t(1;19) (E2A-PBX1)
DG
chromosomes 4, 10, and 17 centromeric probes
DG
Chr 9p21 (CDKN2A)
DG
FMF
Lab Use Only
DG
Myeloproliferative Neoplasm: PDGFRA/B, FGFR1
DG
FISH M/F
DG
Other (Specify)
DG
Ordering Physician's Printed Name:____________________ Signature:____________________________Date:___________Time: ______ a.m.
p.m.
Phys. Billing #______________
Lab # ________________________________
Date and Time Specimen Received:
Hematopathology
Vanderbilt University Medical Center
1301 Medical Center Drive
4605 TVC
Nashville, TN, 37232
(615) 343-9167
DG
DG
Lymphoma
Follicular Lymphoma: t(14;18)
FISH
TEL
ICD
FISH (cont.)
Molecular Genetics: Somatic Alterations
IGR
LV
Tube Color
Test
ICD
LV, DG
Flow Cytometry Laboratory
Vanderbilt University Medical Center
1301 Medical Center Drive
4605 TVC
Nashville, TN, 37232
(615) 343-9081
_______/_______/_______
[__] a.m.
Molecular Genetics Laboratory
Vanderbilt University Medical Center
1301 Medical Center Drive
4605 TVC
Nashville, TN, 37232
(615)-343-8121
[__] p.m.
Cytogenetics Laboratory
Vanderbilt University Medical Center
21129 One Hundred Oaks
719 Thompson Lane
Nashville, TN, 37204
(615) 936-7817
MC 6447F
9/15/2015