Rev. 030918

Tech-Only Qualitative IHC/ISH/Special Stains

For a complete list of our test menu, please visit neogenomics.com

□ AACT □ AAT □ ACTH □ AFP □ ALK-1 (Heme) □ Annexin A1 □ AR □ Arginase 1 □ ATRX □ B72.3 □ BAP1 □ BCA-225 □ BCL1/Cyclin D1 □ BCL2 □ BCL6 □ BerEP4 □ Beta Catenin □ BG8 □ BOB1 □ Breast Triple Stain (CK5+p63+CK 8/18) □ CA19.9 □ CA125 □ Calcitonin □ Caldesmon □ Calponin □ Calretinin □ CAM 5.2 (CK LMW) □ Carbonic Anhydrase IX (CA IX) □ CD1a □ CD2 □ CD3 □ CD4 □ CD5 □ CD7 □ CD8 □ CD10 □ CD11c □ CD14 □ CD15 □ CD19 □ CD20 □ CD21 □ CD22 □ CD23 □ CD25 □ CD30 □ CD31 □ CD33

□ CD34 □ CD35 □ CD38 □ CD42b □ CD43 □ CD44 □ CD45 (LCA) □ CD45RB □ CD45RO □ CD56 □ CD57 □ CD61 □ CD68 □ CD71 □ CD79a □ CD99 □ CD117 cKIT □ CD123 □ CD138 □ CD163 □ CDK4 □ CDX2 □ CDX2/CK7 Double Stain □ CEA (Mono) □ CEA (Poly) □ Chromogranin A □ CK 5/6 □ CK 7 □ CK 10/13 □ CK 14 □ CK 17 □ CK 18 □ CK 19 □ CK 20 □ CK HMW (CK903/34βBE12) □ CK HMW/LMW Double Stain □ CK OSCAR □ cMyc □ Collagen IV □ cREL □ CXCL13 □ D240 □ DBA.44 □ Desmin □ DOG1 □ DPC4 □ E-Cadherin □ Eg5 □ EMA □ ER □ ERG

□ AcP □ AFB □ Alcian Blue □ Calcium Stain □ Chloroacetate Esterase (CAE) □ Colloidal Iron □ Congo Red □ Copper Stain □ Elastic Stain □ Fite □ Fontana Masson □ Giemsa □ GMS □ Gram Stain □ Hall Bile Stain □ Iron □ MPO Cytochemical □ Mucicarmine □ Naphthol Acetate Esterase w/o sodium fluoride inhibition □ Naphthol Acetate Esterase w/sodium fluoride inhibition □ Naphthol Butyrate Esterase (NBE) □ PAS □ Periodic Acid Schiff for Fungus (PASF) □ Periodic Acid Schiff with Digestion (PASD) □ Reticulin □ TRAP Cytochemical □ Trichrome □ Warthin Starry □ Wright Giemsa

Special Stains (Tech-Only)

In-Situ Hybridization (Tech-Only)

□ EBER ISH □ Kappa/Lambda ISH □ Other (Specify):

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□ Factor VIII □ Factor XIIIa □ Fascin □ Fli-1 □ FOXP1 □ FOXP3 □ FSH □ Galectin 3 □ Gastrin □ GATA3 □ GCDFP15 □ GCET1 □ GFAP □ GH □ Glucagon □ Glutamine Synthetase □ GLUT1 □ Glycophorin A □ Glypican-3 □ Granzyme B □ HBME1 □ HCG Beta □ Hemoglobin A □ HepPar1 □ HGAL □ HLA-DR □ HMB45 □ HPL □ IDH1 □ IgA □ IgD □ IgG □ IgG4 □ IgM □ Inhibin □ INI1 □ iNOS □ Insulin □ Kappa/Lambda IHC □ Ki67 □ Ki67/Caspase 3 (Double Stain) □ Laminin □ Langerin □ LEF1 □ LH □ LMO2 □ Lysozyme □ MAL □ Mammaglobin □ MDM2 □ Melan A (Mart1) □ Mesothelin

Mismatch Repair (MMR) □ MLH1 □ MSH2 □ MSH6 □ PMS2 □ All 4 Stains

□ MITF □ MOC31 □ MPO □ MSA □ MUC1 □ MUC2 □ MUC4 □ MUC5 □ MUC6 □ MUM1 □ MyoD1 □ Myogenin □ Myoglobin □ Napsin A □ NeuN □ NF (Neurofilament) □ NKX2.2 □ NKX3.1 □ NSE □ OCT2 □ OCT4 □ Olig2 □ p16 □ p40 □ p53 □ p57 □ p63 □ p120 Catenin □ p501S □ p504S □ Pan-Cytokeratin □ Pan Melanoma (S100+Melan A+Tyrosinase) □ Pan-Melanoma/Ki67 □ Parafibromin □ PAX2 □ PAX5 □ PAX8 □ PD1 □ Perforin □ PgR □ PLAP □ Prealbumin (TTR) □ Prolactin □ Prostate Triple Stain □ PSA

□ PSAP/HPAP □ PSMA □ PTH □ PU.1 □ RCC1 □ S100 □ S100p □ SALL4 □ SATB2 □ Serotonin □ SF1 □ SMA □ SMMHC □ Smoothelin □ Somatostatin □ Somatostatin Receptor, Type 2 □ SOX10 □ SOX11 □ SOX2 □ STAT6 □ Surfactant □ Synaptophysin □ TCL1 □ TCR BetaF1 □ TdT □ TFE3 □ Thrombomodulin (TM) □ Thyroglobulin (TGB) □ TIA1 □ TLE1 □ TRAcP □ Tryptase □ TSH □ TTF1 □ Tyrosinase □ Uroplakin II □ Uroplakin III □ Villin □ Vimentin □ WT1 □ ZAP70

G T□□ Adenovirus □□ Cat Scratch □□ CMV (IHC)□□ CMV (ISH)□□ EBER ISH (head & neck) N/A□ EBER ISH (heme)N/A □ EBV (LMP1) □□ H. Pylori □□ Hep B Core Antigen□□ Hep B Surface Antigen

□□ HHV8 □N/A HPV RNA ISH Panel (Complete)□N/A HPV RNA ISH 16/18 High Risk□N/A HPV RNA ISH High Risk Cocktail□N/A HPV RNA ISH Low Risk Cocktail□□ HSV I/II

G T□□ Parvovirus □□ Pneumocystis Carinii (Jiroveci)□□ Spirochete □□ SV40 □□ Toxoplasma □□ Tuberculosis□□ Varicella Zoster Virus (VZV)

G TInfectious Disease

Semi-QuantitativeG T□□ BCL1/Cyclin D1 □□ BCL2□□ BRCA1□□ Cathepsin D □□ cMET □□ COX2 □□ EGFR □□ eIF4E □□ ERCC1 □□ GST Pi□□ HER2 Dual ISH□□ HER2 Non-Breast** □□ MGMT

□□ p21 □□ p27□□ pAKT □N/A PD-L1 22C3 FDA (KEYTRUDA®)□N/A PD-L1 22C3 FDA (KEYTRUDA) for Gastric/GEA□N/A PD-L1 28-8 FDA (OPDIVO®)□N/A PD-L1 SP142 FDA (TECENTRIQ®)

G T □N/A PD-L1 SP263 FDA (IMFINZI™) □□ pHistone H3 (PHH3) □□ PTEN □□ Retinoblastoma Protein (RB)□□ RRM1□□ Survivin □□ Tau □□ TGF Alpha□□ TOPO1 □□ TS □□ VEGF

G T

QualitativeG T□□ ALK, D5F3 (lung, FDA) □□ Amyloid A□□ Amyloid P□□ BRAF V600E □□ Carcinoma Micromets (levels with AE1/AE3)□□ Congo Red□□ EGFR (L858R mutant specific)

□□ EGFR (E746-A750del specific)□□ Melanoma Micromets (HMB45 with Melan A/Mart1) □□ p16□□ PD1□N/A pERK□□ ROS1

G T

G T□□ AFB □□ Fite □□ Gram Stain

Infectious Disease Special Stains

□□ GMS□□ Periodic Acid Schiff for Fungus (PASF)□□ Warthin Starry

G T

Prognostic Markers □ Add global prognostic interpretation

IHC/ISH/Special Stains with Level of Service Options

**For global HER2 IHC with result 2+, NeoGenomics will add global HER2 FISH unless marked here: □ Do not reflex 2+

□□ □ AR □□ □ ER□□ □ HER2 Breast**□□ □ Ki67□□ □ MLH1

Image Analysis/Semi-Quantitative IHCG-IA T-IA T-SQnt □□ □ MSH2□□ □ MSH6□□ □ p53□□□ PMS2□□ □ PgR

G-IA T-IA T-SQnt

Required InformationAccount #: __________________ Account Name: ____________________________________

Street Address: ________________________________________________________________

________________________________________________________________

City, ST, ZIP: ___________________________________________________________________

Phone: _________________________________ Fax: __________________________________

□Surgical Pathology Consult □ Do not add NeoTYPE®/NeoLAB™ testing

Consultation - A NeoGenomics pathologist will select medically necessary tests (with any exception noted below by the client) to provide comprehensive analysis and professional interpretation for the materials submitted.

Differential Diagnosis: _______________________________________________________________

Client represents it has obtained informed consent from patient to perform the services described herein.

Immunohistochemistry and Special Stain Requisition

Specimen Information

Client Information

Specimen ID:* ________________________ Block ID:* _______________________________Fixative/Preservative: _____________________________________________________________Collection Date: mm ________ / dd ________ / yyyy ___________ Collection Time: _______ □ AM □ PMRetrieved Date: mm ________ / dd ________ / yyyy ___________

Hospital Discharge Date: mm ________ / dd ________ / yyyy ___________

Body Site: ____________________________________________________________________□ Primary □ Metastasis – If Metastasis, list Primary: ____________________________________

□ Fresh Tissue (Media Type required): _________________________________________________

□ FNA cell block: _______________________________________________________________

□ Smears: Air Dried ________ Fixed ________ Stained (type of stain) ____________________

□ Slides # _________ Unstained _________ Stained ________ □H&E _________________

□ Paraffin Block(s) #: ____________ □ Choose best block (global testing only) □ Perform tests on all blocks *NeoGenomics makes every effort to preserve and not exhaust tissue, but in small and thin specimens, there is

a possibility of exhausting the specimen in order to ensure adequate material and reliable results.

Clinical Information□ Diagnosis Code/ICD Code (Required): ___________________________________________Reason for Referral: _____________________________________________________________□ New Diagnosis □ Relapse □ In Remission □ MonitoringStaging: □ 0 □ I □ II □ III □ IV Note:_______________________Attach all relevant clinical history, pathology/cytology report(s) and other applicable test report(s)

Patient InformationLast Name: __________________________________________________________________

First Name: ____________________________________ M.I. ________ □ Male □ Female

Date of Birth: mm ________ / dd ________ / yyyy __________ Medical Record #: _________________

Phone 866.776.5907/ Fax 239.690.4237neogenomics.com

Billing InformationRequired: Please attach Patient Pathology Report. Please include face sheet and front/back of patient insurance/Medicare/Medicaid card ONLY if requesting Neo bill patient insurance.Specimen Origin (Must Choose 1): □ Hospital Patient (in) □ Hospital Patient (out) □ Non-Hospital PatientBill to: □ Client Bill □ Other Hospital/Facility: _______________________________________________ □ Insurance □ Medicare □ Medicaid □ Patient/Self-Pay □ Split Billing - Client (TC) and Insurance (PC) Prior Authorization #_______________________________________ See the NeoGenomics.com Billing section for more info.Client agrees that in the event of incorrect designations and NeoGenomics is unable to bill a Third Party Payer under the current rules in effect for such payer, then NeoGenomics is authorized to bill the Client for any such incorrectly designated tests and Client will pay for such charges.

Requisition Completed by: _______________________________________ Date: ______________

Ordering Physician (please print: Last, First): ____________________________ NPI #: ______________

Treating Physician (please print: Last, First): ________________________________________________The undersigned certifies that he/she is licensed to order the test(s) listed below and that such test(s) are medically necessary for the care/treatment of this patient.

Authorized Signature: ____________________________________ Date: __________________

Breast Marker & GI HER2 Fixation (CAP/ASCO Requirement for Breast and Non-Breast)Cold ischemic time ≤ 1 hour: □ Yes □ No □ Unknown10% neutral buffered formalin: □ Yes □ No □ UnknownHER2/ER/PgR Fixation duration 6 to 72 hours: □ Yes □ No □ Unknown

G - Global G-IA - Global with Image Analysis T - Tech-Only/Stain-Only T-IA - Tech-Only with Image Analysis T-SQnt - Tech-Only with Semi-Quantitative interpretation by client

Specimen RequirementsRefrigerate specimen if not shipping immediately and use cool pack during transport. Please call Client Services Team with any questions regarding specimen requirements or shipping instructions at 866.776.5907 option 1. Please refer to the website for specific details on each specimen.

Additional Billing InformationAny organization referring specimens for testing services pursuant to this Requisition form (“Client”) expressly agrees to the following terms and conditions.

1. Binding Service Order. This Requisition Form is a legally binding order for the services ordered hereunder and Client agrees that it is financially responsible for all tests billable to Client hereunder.

2. Third Party Billing by NeoGenomics for Tests. Client agrees that, except for those Services requiring direct Client billing as described in paragraphs 3 and 4 below, NeoGenomics shall, whenever possible and when permitted by applicable third party payer rules and applicable laws, directly bill and collect from all federal, state and commercial health insurers, health maintenance organizations, and other third party payers (collectively, the “Payers”), for all services ordered pursuant to this Requisition Form (“Services”). For all such Services billable to Payers, Client agrees to indicate on the front of the Requisition Form that NeoGenomics should bill the appropriate Payer directly and provide all billing information necessary to bill such payer.

3. Right to Bill Client. In the event NeoGenomics: (i) does not receive the billing information required for it to bill any Payers within ten days of the date that any Services are reported by NeoGenomics; (ii) the Services were performed for patients who have no Payer coverage arrangements; or (iii) the Payer identified by Client denies financial responsibility for the Services and indicates that Client is financially responsible, NeoGenomics shall have the right to bill such Services to Client. In the event that Client subsequently provides NeoGenomics with billing information for such tests before paying the related invoice, then Client may pay the invoiced amount less any amounts for tests in which billing information was subsequently provided.

4. Client Billing for Certain Tests. NeoGenomics shall not directly bill Payers for Services when: (i) direct third party billing is not permitted by applicable laws or Payer requirements or policies; or (ii) Client receives reimbursement for the provision of Services on a non-fee-for-service basis, including, but not limited to, reimbursement paid to Client pursuant to a capitated, diagnostic related group (DRG), per diem, all-inclusive, or other such bundled or consolidated billing arrangement; or (iii) Client receives reimbursement for the provision of Services from Medicare pursuant to outpatient Ambulatory Payment Classifications; or (iv) NeoGenomics is not contracted with a Payer for the Services ordered and Client is otherwise eligible to be reimbursed on a fee for service basis from such Payer. In all such cases, Client shall notify NeoGenomics of such billing arrangements by indicating that Client should be billed on the front of the Requisition Form.

Test Descriptions and NotationsHPV RNA ISH Panel: Complete panel includes all three of the following components which can be ordered separately as noted on the front of the requisition. a) 16/18 High Risk. b) High Risk Cocktail (18 subtypes): 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, 82. c) Low Risk Cocktail (10 subtypes): 6, 11, 40, 43, 44, 54, 69, 70, 71, 74.

© 2018 NeoGenomics Laboratories, Inc. All Rights Reserved.All other trademarks are the property of their respective owners.Rev. 030918