Order a Test

APOL1 Genetics Test Requisition form

Patient First Name Patient Last Name Patient's Birth Date [MM/DD/YYYY]
Patient Phone Patient Email MRN #
Sex

Collection information

Collection Date [MM/DD/YYYY]
Collection time (hours, minutes, AM or PM) Phlebotomist First Name Phlebotomist Last Name Diagnosis or ICD-10 Code

Referring Physician Information

Referring Physician First Name Referring Physician Last Name Letters (MD/DO)
Provider NPI Number Institution Name Institution Street Address Institution City Institution State
Institution Zip Code Referring Physicial Phone Number Referring Physician Fax Referring Physician Email

Test Information

APOL1 Genotyping, Test Required - Tube Types Legend

The APOL1 genetic test is provided for a fee of $375. Submitting this requisition form acknowledges your responsibility for the total payment of the genetic test. This amount should not be reimbursed at the Medicare rate as this charge should not be submitted to insurance companies nor will patients be billed directly. Request for testing and payment must be fulfilled by a clinical entity. An invoice cannot be sent directly to a patient.

Is the billing information the same as the referring physician?

Specimen and Shipping Requirements

Acceptable specimens include:

Potential living donors and patients (results provided within 7 days of receiving the samples)

Peripheral blood: At least 2 Lavender top (EDTA) tubes or Yellow top (ACD-A) tubes. Shipped overnight at room temperature.

Please ensure the mailer meets all IATA and DOT requirements for shipping of diagnostic specimens through FedEx or UPS.

Please email us at hlalab@wakehealth.edu to discuss specimen requirements for deceased donors and rapid genetic testing (same business day).

All samples must have two patient identifiers, specifically the patient’s name and date of birth. Each sample must be accompanied by a printed copy of this completed requisition form, which you will receive by email after submitting. The ordering provider must agree to the terms of agreement outlined below.

Sample with a printed copy of the completed requisition form should be shipped to:

HLA/Immunogenetics Laboratory
145 Kimel Park Drive, Suite 250
Winston-Salem, NC 27103

Please contact HLA/Immunogenetics Laboratory at +1.336.716.4456.

How would you like to receive your results?

Terms of Agreement

Enter the name of the person completing this form.

Contact Person First Name Contact Person Last Name Contact Person Email

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By submitting this form I certify that the above facts are true to the best of my knowledge and hereby submit the above information to the HLA/Immunogenetics Laboratory at Wake Forest Baptist Medical Center.

We understand that your privacy is important. Our privacy policy describes our practices.

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