ExecutiveCheckUp_Dec4_Men_EnglishVersion 2

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noven,ed.J.Dg..og_jbyDr;'vlaxCARDIAC ConditionsHereditary AssessmentRequisitionCity State ZipPhysicianNameAddressPhone DOB Gender City StateD Male D FemaleAncestryEmailD CaucasianD Western EuropeanD African AmericanD CaribbeanD Ashkenazi JewishD Eastern EuropeanD Native AmericanD AsianD Central/South AmericanD HispanicD Northern European0 Middle EasternD Pacific IslanderD Other:FaxPaben! has had a blood transfusion B s1- ------------------------------------1 2-4 weeks of wan time is required for some testing.PLEASE PROVIDE LIST OF CURRENT MEDICATIONSName ofPolicyholderRelabonship to Policyholder4. BILLING INFORMATIONZipEmailPhoneIf "Yes" - Date of the last transfusion:Specimens are not accepted for patients who have had allogeneic bone marrow transplants.BILL: D Insurance D HSA D Medicaid D Medicare D Se Pay D Worl<er's Compensation□ Se □ Spouse □ Dependant □ Other _____________________ _DOB:Medicare#Worker's CompClaim#Medicaid#Dateof InjuryICD-10 DIAGNOSIS CODES: _ _ _□ CARDIAC PANEL - 174 GENESABCC9, ABCG5, ABCG8, ACTA1, ACTA2, ACTC1, ACTN2, AKAP9, ALMS1, ANK2ANKRD1, APOA4, APOA5, APOB, APOC2, APOE, BAG3, BRAF, CACNA1C, CACNA2D1CACNB2, CALM1, CALR3, CASQ2, CAV3, CBL, CBS, CETP, COL3A1, COL5A1, COL5A2COX15, CREB3L3, CRELD1, CRYAB, CSRP3, CTF1, DES, DMD, DNAJC19, DOLK, DPP6DSC2, DSG2, DSP, DTNA, EFEMP2, ELN, EMO, EYA4, FBN1, FBN2, FHL1, FHL2, FKRPFKTN, FXN, GAA, GATAD1, GCKR, GJA5, GLA, GPD1L, GPIHBP1, HADHA, HCN4HFE, HRAS, HSPB8, ILK, JAG1, JPH2, JUP, KCNA5, KCND3, KCNE1, KCNE2, KCNE3KCNH2, KCNJ2, KCNJ5, KCNJ8, KCNQ1, KLF10, KRAS, LAMA2, LAMA4, LAMP2, LDB3,LDLR, LDLRAP1, LMF1, LMNA, LPL, LTBP2, MAP2K1, MAP2K2, MIB1, MURC (CAVIN4)MYBPC3, MYH11, MYH6, MYH7, MYL2, MYL3, MYLK, MYLK2, MYO6, MYOZ2m MYPNNEXN, NKX2-5, NODAL, NOTCH1, NPPA, NRAS, PCSK9, PDLIM3, PKP2, PLN, PRDM16PRKAG2, PRKAR1A, PTPN11, RAF1, RANGRF, RBM20, RYR1, RYR2, SALL4, SCN1BSCN2B, SCN3B, SCN4B, SCN5A, SCO2, SDHA, SEPN1, SGCB, SGCD, SGCG, SHOC2SLC25A4, SLC2A10, SMAD3, SMAD4, SNTA1, SOS1, SREBF2, TAZ, TBX20, TBX3, TBX5TCAP, TGFB2, TGFB3, TGFBR1, TGFBR2, TMEM43, TMPO, TNNC1, TNNI3, TNNT2TPM1, TRON, TRIM63, TRPM4, TTN, TTR, TXNRD2, VCL, ZBTB17, ZHX3, ZIC36. PATIENT CONSENT 7. MEDICAL NECESSITY FOR TESTINGBilling ABN and Patient Plan Information: A completed Advance Beneficiary Notice (ABN) of coverageis required for Medicare patients who do not meet medical criteria for testing. This does not apply to specificsite analyses. Insurance pre-qualification will not be performed for these tests, unless specifically requested.All tests ordered shall be processed and billed based on payor.Patient Acknowledgment: I am covered by insurance and authorize Novomed Specialized Clinics togive my designated insurance carrier(s) plan on this form and other informabon provided by my health careprovider necessary for reimbursement. I authorize Novomed Specialized Clinics to inform my Plan of mytest results only if test results are required for preauthorizabon of or payment for reflex/additional testing.I authorize Plan benefits to be payable to Novomed Specialized Clinics. I further authorize payment ofbenefits directly to the laboratory. I understand acceptance of insurance does not relieve me from anyresponsibility concerning payment for laboratory services and that I am financially responsible for all chargeswhether or not they are covered by my insurance. I understand that any payment I receive for servicesrendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory.The data may also reveal secondary or incidental findings, such as that you may be at risk for certaingenebc diseases or that you are a carrier of disease associated mutations.Patient Consent: My signature below consrnutes my acknowledgment that the benefits, risks, andlimnations of this testing have been explained to my satisfaction by a qualified health professional andI have received a copy of the full informed consent document. I have been given the opportunity to askquestions before I sign, and I have been told that I can ask questions at any other time. I voluntarilyagree to genetic testing.Patient Consent for Research: □ By checking this box I DO NOT consent for the remaining partof my sample to be used for research purposes by Novomed Specialized Clinics.Personal information will not be shared and will be kept confidenbal by Novomed Specialized Clinics.If Signature is other than patent's. Printed Name ________________ __,This test is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndromeor disorder, and these results will be used in the medical management and treatment for this patient.Furthermore, recipients' information is true and correct to the best of my knowledge.The person listed as the Ordering Physician or genebc counselor is authorized by law to order the test(s)requested herein. I confirm that I have provided genetic tesbng informabon to the patient and they haveconsented to genetic testing.Please check all that apply:□ I confirm that the above patient's gene testing is medically necessary and the result will be usedto assess pabent for Mure cardiac conditions risk.□ I agree to allow Novomed Specialized Clinics to transfer the information contained in thisrequisibon to an LMN (Letter of Medical Necessity) using the ordering physician's name as his/hersignature for insurance billing purposes.D I have attached a LMN for insurance billing purposes.D Patient meets clinical/genetic tesbng criteria for the above ordered tests.0----------------------------------t"lilHEALTH CARE PROVIDER'S SIGNATURETEST SUBMISSION CHECKLISTD Copy of Patient DemographicsCollected by:D Current Meds ListlOD ICD-10 Diagnosis Codes Print Name D Patient's/Provider's SignaturesD Copy of Insurance Card (Front/Back)i.IllPATIENT'S OR RESPONSIBLE PARTY'S SIGNATURE DATE□ Attach Patient's Insurance Pre-Authorizaton Form Sgnature 1l,_ _________________________________ ___. __________________________________ _,oNovomed Specialized Clinics • Suite 3002 - 3005 30th Floor, Marina Plaza, Dubai Marina, Dubai, UAE • Phone : 971 4 247 3100Tests are performed in USA, results in one week.DATE
nove,ned· ,. .1.Dg.Dg.JbyVr;\1axCardiovascular Genetics ICD-10 Code Reference SheetCODE142.0142.2142.8143142.8145.81146.2148.0148.91149.1149.5023.8R00.2H27.10H52.12134.1171.01171.1171.9177.810J93.11J93.81L90.6M35.7O66.0067.6068.1087.410087.42R23.3E75.5E78.01E78.2E78.4H18.411H18.413125.10125.700125.720125.750125.790G71.0134.0O23.0087.89R06.02Z13.6Z86.74Z95.2Z14.8Z82.41Z82.69Z83.42Z84.89DESCRIPTION CODE DESCRIPTIONCARDIOMYOPATHYDilated cardiomyopathy 142.1 Hypertrophic obstructive cardiomyopathyHypertrophic non-obstructive cardiomyopathy 142.5 Cardiomyopathy, other restrictiveOther cardiomyopathies 142.9 Cardiomyopathy, unspecifiedSyndromic cardiomyopathy 151.7 Ventricular hypertrophyARRHYTHMIAArrhythmogenic right ventricular dysplasia (ARVD) 144.2 Atrioventricular block, completeLong QT syndrome 145.89 Other specified conduction disordersCardiac arrest due to underlying cardiac condition 147.2 Ventricular tachycardiaParoxysmal atrial fibrillation 148.2 Chronic atrial fibrillationUnspecified atrial fibrillation 149.01 Ventricular fibrillationAtrial premature depolarization (PACs) 149.3 Ventricular premature depolarization (PVCs)Sick sinus syndrome 149.8 Other specified cardiac arrhythmiasBrugada syndrome R00.1 Bradycardia, unspecifiedPalpitations R94.31 Abnormal electrocardiogram (ECG)(EKG)AORTIC ANEURYSMS/MARFAN SYNDROMEUnspecified dislocation of the lens H52.11 Myopia, right eyeMyopia, left eye H52.13 Myopia, bilateral eyesMitral valve prolapse 171.00 Dissection of unspecified site of aortaDissection of thoracic aorta 171.01 Dissection of abdominal aortaThoracic aortic aneurysm, ruptured 171.2 Thoracic aortic aneurysm, without ruptureAortic aneurysm of unspecified site, ruptured 171.9 Aortic aneurysm of unspecified site, without ruptureThoracic aortic ectasia J93.0 Spontaneous tension pneumothoraxPrimary spontaneous pneumothorax J93.12 Secondary spontaneous pneumothoraxChronic pneumothorax J93.83 Other pneumothoraxStria Atrophicae (stretch marks) L98.8 Other specified disorders of skin and subcutaneous tissueHypermobility Syndrome 012.1 Congenital displaced lensCongenital Talipes Equinovarus ("club foot") 067.5 Congenital deformity of the spine (scoliosis)Pectus excavatum 067.7 Pectus CarinatumArachnodactvlv ("Conaenital deformitv of finaer(s) and hand") 087.40 Marfan svndromeMarfan syndrome with aortic dilation 087.418 Marfan syndrome with other cardiovascular manifestationsMarfan syndrome with ocular manifestations087.43 Marfan syndrome with skeletal manifestationsSpontaneous Ecchymoses (easy bruising)CHOLESTEROL/CORONARY ARTERY DISEASEOther lipid storaae disorders E78.0 Pure h'{PercholesterolemiaFamilial hypercholesterolemia E78.1 Pure hyperglyceridemiaMixed hyperlipidemia E78.3 HyperchylomicronemiaOther hyperlipidemia E78.5 Hyperlipidemia, unspecifiedArcus senilis, right eve H18.412 Arcus senilis, left eveArcus senilis, bilateral eves 120.0 Unstable anginaAtherosclerotic heart disease of native 125.110 Atherosclerotic heart disease of native coronarycoronarv artery without anaina oectorisartery with unstable anaina oectorisAtherosclerosis of coronary artery bypass graft(s), 125.710 Atherosclerosis of autologous vein coronaryunsoecified with unstable anaina oectorisarterv bvoass araft/s) with unstable anaina oectorisAtherosclerosis of autologous artery coronary artery 125.730 Atherosclerosis of nonautogous biological coronarybvoass graft(s) with unstable angina oectorisarterv bvoass graft(s) with unstable anaina oectorisAtherosclerosis of native coronary artery of transplanted 125.760 Atherosclerosis of bypass graft of coronary arteryheart with unstable angina pectorisof transplanted heart with unstable angina pectorisAtherosclerosis of other coronary artery bypass T46.6X5A Adverse effect of antihyperlipidemic andgraft(s) with unstable angina pectorisantiarteriosclerotic drugs (statin intolerance)OTHERHereditary progressive muscular dystrophy 110 Essential (primary) hypertensionMitral valve prolapse 146.9 Cardiac arrest, cause unspecifiedAortic stenosis, congenital 020.9 Congenital heart disease (NOS)Noonan svndrome R55 Svncooe and collapseShortness of breath Z01.810 Encounter for oreorocedural cardiovascular examinationEncounter for screening for cardiovascular conditions Z79.01 Long term (current) use of anticoagulantsPersonal history of sudden cardiac arrestPresence of prosthetic heart valveZ95.0 Presence of cardiac pacemakerFAMILY HISTORYGenetic carrier of other disease Z15.89 Genetic susceptibility to other diseaseFamily history of sudden cardiac death Z82.49 Family history of ischemic heart disease andother diseases of the circulatorv svstemFamily history of other diseases of the Z82.69 Family history of other congenital malformations,musculoskeletal system and connective tissuedeformations and chromosomal abnormalitiesFamily history of familial hypercholesterolemiaFamily history of other specified conditionsZ84.81 Family history of carrier of genetic diseaseNovomed Specialized Clinics • Suite 3002 - 3005 30th Floor, Marina Plaza, Dubai Marina, Dubai, UAE • Phone : 971 4 247 3100Tests are performed in USA, results in one week.
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(Sample)Report of ComprehensiveHeal
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Our focus on providing the most com
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Summary of Medical Examination• E
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Nutritional Diet92% of food and nut
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The obesity criteria is defined as
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This is a test to check the number
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Cardiovascular ExamsLipid blood tes
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ًStress Echocardiography ReportCar
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Male HormonesTestosteroneDehydroepi
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Page 33 and 34: Metabolic SyndromeMetabolic syndrom
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Page 53 and 54: resultsguidebooka step by step guid
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Page 63 and 64: FAQsDo I have to avoid alcohol all
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