If you have questions, please call the BMT Authorization Specialist at , ext 5028 for assistance.

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1 Date: Dear Dr. ; Thank you for choosing Children s Hospital & Research Center Oakland to perform the HLA typing for your patient. Please find enclosed an HLA Intake form, sample handling instructions, and a Molecular HLA Typing Request Form. The HLA Intake Form is a standard patient and financial information questionnaire that must be completed prior to our performing the HLA typing. It is very important that the authorization from the patient s insurance or other payer is in place when the referral is sent. If we do not receive the authorization, this can delay the completion of HLA typing. Please find enclosed a list of the laboratory tests that we perform and their corresponding CPT codes. The number of tests performed varies among individuals. Questions regarding the tests should be directed to the transplantation physician. The cost of comprehensive molecular HLA typing varies depending on the individual tested and the level of resolution required; this charge is not insignificant. If you have questions, please call the BMT Authorization Specialist at , ext 5028 for assistance. It takes a minimum of 2 weeks after we receive the samples and complete documentation to report the results. The results will be mailed to your address as listed in the HLA Intake Form. Sincerely, Mark Walters, MD Director, BMT Program Director Elizabeth A. Trachtenberg, PhD. dipl.abhi Director, HLA Laboratory 747 Fifty Second Street Oakland, CA

2 HLA Intake Form - Page 1 of 3 HLA Intake Form PLEASE NOTE: It is the responsibility of the referring physician to obtain authorizations from the patient s insurance or other third party payer before HLA typing can commence. All requested services must be accompanied by an insurance authorization upon receipt of the specimen. Please also find enclosed instructions for obtaining and sending blood specimens to Children s Hospital & Research Center Oakland for HLA typing and a requisition form that contains vital patient and family information. All requested information and proper labeling of samples must be completed before HLA typing can proceed. Failure to complete the requisition or to submit an approved authorization will delay completion of the HLA typing. Please contact us if there are unusual or compelling financial hardships that you would like us to consider. Once completed, FAX the HLA Intake Form and the authorization information from the insurance company to: Sue Kuzmicky at fax # Date of request: Fax # address: Referring physician: Phone number: Referring physician address: Patient s name: First Middle Initial Last Date of birth: / / Social Security #: Diagnosis: ICD-9 code: Primary Patient s home address: Mother s name: Social Security #: Father s name: Social Security #: Number of potential donors to be tested: Are any of these not full biological siblings? Yes No Financial Information: Guarantor s Name: First Middle Initial Last Relationship: Date of birth: Social Security #: Guarantor s address: Employer: Work phone number: Employer Address:

3 HLA Intake Form - Page 2 of 3 Primary Insurance: Attach copy of front and back of the insurance card and authorization from insurance company Company name: Claim submission address: Subscriber s name: Membership #: Plan/Group #: Authorization: This test is a benefit of the patient s insurance: Yes No Insurance contact person: Insurance phone #: If answer is no what arrangements are to be made for the payment of services? Secondary Insurance: Attach copy of front and back of the insurance card and authorization from insurance company Company name: Claim submission address: Subscriber s name: Membership #: Plan/Group #: Authorization: This test is a benefit of the patient s insurance: Yes No Insurance contact person: Insurance phone #: If answer is no what arrangements are to be made for the payment of services? Emergency Contact: Name: Phone number: Address: Laboratory tests to be requested for authorization and quantity Quantity of tests is variable based upon individual case. Molecular HLA CPT Codes DNA Extraction Probe Array TC High Purity DNA Extract Interpretation DNA Sequencing Interp. Probe Array Sample Amp Probe Array TC Separation Gel Interp. Probe Array Probes (ea) 83896

4 HLA Intake Form - Page 3 of 3 Potential Donor Information: immediate family members (parents and siblings): Use additional pages, if necessary; complete information is required for all family members.

5 Children s Hospital & Research Center Oakland HLA LABORATORY (CA Lab ID #CLF11270, CLIA #05D ) nd Street, Bruce Lyon Research Building, Rm. 204 Oakland, CA (510) ; FAX (510) REQUEST for MOLECULAR HLA TYPING Elizabeth Trachtenberg, PhD, dipl. ABHI, Director (CA Lic.# DRK24) and/or Post TX Engraftment Studies Please complete ALL columns Recipient(s) Name(s) 1 DOB Ethnic Group Sex Relation to Recip MR# ICD-9 Code/Dx Class I/II Typing or Chimerism Source (e.g. PB, catheter, etc) Date of Collection Drawn By (Initials) 2 1 Donor(s) DOB Ethnic Group Sex Relation to Recip # MR# (if avail.) Class I/II Typing or Chimerism Source (e.g. PB, catheter, etc) Date of Collection Drawn By (Initials) Is maternal donor currently pregnant? Yes No Requested by: Date: (Physician Signature Required) Address: Phone: Fax: Molecular HLA CPT Codes DNA Extraction High Purity DNA Extract DNA Sequencing Sample Amp Separation Gel Probes (ea) Interpretation Probe Array TC Interp. Probe Array Probe Array TC Interp. Probe Array Interpretation 83912

6 HLA Specimen Requirements & Shipping Information A. Whole Blood Collection Criteria: 1. Tubes should be EDTA (purple top) or ACD (yellow top) only. DO NOT USE HEPARIN (green top). 2. Collect a minimum of 0.2 ml to 2 ml whole blood. 3. DO NOT OPEN TUBES, UNDER ANY CIRCUMSTANCES: Vacuum seal cannot be broken on tube. Blood must be transferred with a needle or butterfly if a syringe is used in collection of sample. Opening tubes may contaminate the sample, as our typing system is able to detect as little as one to a few MOLECULES! Contaminating molecules could potentially be typed along with the sample s leading to anomalous results and necessitating recollection of sample for retyping. 4. Label tubes with: FULL NAME, DOB, DATE OF SPECIMEN, and DRAWER S INITIALS. 5. Check that all required information is filled out on request form. The requesting physician s signature and address/phone must be on this form. B. Amniotic Fluid or CVS Specimen Collection Criteria: 1. Samples should be collected and stored using sterile precautions. 2. Collect a minimum of 10 ml amniotic fluid, and/or a minimum of ~ 1 x 10 6 cultured amniotic or CVS cells. 3. Once samples are collected, DO NOT OPEN TUBES UNDER ANY CIRCUMSTANCES: Opening tubes may contaminate the sample, as our typing system is able to detect as little as one to a few MOLECULES! Contaminating molecules could potentially be typed along with the sample s leading to anomalous results and necessitating recollection of sample for retyping. 4. Proceed with steps #4-5 in (A) above. C. Cultured Cells or Cell Pellet Specimen Criteria: 1. Samples should be collected and stored using sterile precautions. 2. Cell culture suspensions or cell pellets must contain a minimum of ~ 1X10 6 cells. 3. ONCE ALIQUOTED, DO NOT OPEN TUBES, UNDER ANY CIRCUMSTANCES: Opening tubes may contaminate the sample, as our typing system is able to detect as little as one to a few MOLECULES! Contaminating molecules could potentially be typed along with the sample s leading to anomalous results and necessitating recollection of sample for retyping. 4. Proceed with steps #4-5 in (A) above. D. Note: the Children s Hospital HLA laboratory will reject a sample based on the following criteria: 1. Tubes are unlabelled. 2. Vacuum seal has been broken on whole blood samples. 3. Labels on specimens fail to match information on request form. 4. Specimens are clotted. 5. Blood specimens have been collected in other than EDTA or ACD tubes. 6. Less than 200 ul of blood sample, less than 10 ml amniotic fluid, or less than ~ 1 x 10 6 cultured amniotic or CVS cells has been collected for typing. E. Lab Notification & Sending Of Specimens To Be Typed 1. Store samples in refrigerator at 4 o C until pickup. 2. Notify laboratory of sample delivery: a. Telephone: (510) b. Fax: (510) c. Director: (510) If offsite, send samples by overnight delivery service for arrival Monday-Friday only to: Elizabeth A. Trachtenberg, PhD, dipl. ABHI Director, CHRCO HLA Laboratory Bruce Lyon Research Building, Room nd Street ~ Oakland, CA 94609