Affix Hospital Label or complete: First Name: Last Name: HLA LABORATORY CLIA ID #23D0724117 Medical Record #: 1036 Fuller Ave NE PO Box 1704 Grand Rapids, MI 49501-1704 DOB: Phone (616) 233-8597 1-866-MIBLOOD Fax (616) 233-8658

HUMAN LEUKOCYTE (HLA) TESTING Fill out this form COMPLETELY and send with specimen(s). See reverse for specimen handling. (PLEASE PRINT)

Status:  Inpatient  Outpatient Race Gender:  M  F

Specimen:  Whole Blood  Buccal Swab  Other (specify)

Specimen Collected By: Date/Time Collected: Transfusion History:  None  Unknown  Yes . . . Last Date Products Exposures: Transplant Pregnancies what / when / where number Client: Physician

Hospital Telephone # Fax #

Hospital Address Fax or call report to (if different than above) If testing for outpatient MEDICARE enrollee or MEDICAID recipient, COMPLETE INFORMATION ON REVERSE. Michigan Blood does not directly bill other insurance providers or patients.

Patient/Recipient Transplant Testing:

 Initial Workup Extended Workup  Confirmation/Verification • HLA-A, -B, -C, -DRB1, -DQB1  HLA-DPB1 • HLA- A, -B, -DRB1 • Store specimen  HLA-DPA1  HLA-DQA1  Initial Workup with SAB  KIR • HLA-A, -B, -C, -DRB1, -DQB1  Class I and II ID - High Res (SAB)* • Class I and II antibody ID - High Res (SAB)  Other • Store specimen

Donor – Transplant Testing Specify Relationship to Recipient: For: Recipient Name  Inpatient  Biological Mother  Biological Father  Sibling  Half Sibling NMDP Recipient ID  Outpatient  Child  Other – Explain: RELATED Initial Workup Extended Workup  • HLA-A, -B, -DRB1  HLA-C, -DQB1 • If match, HLA-C, DQB1  HLA-DPB1 • Store specimen  HLA-DPA1  If match, HLA-DPB1  HLA-DQB1 RELATED Confirmation/Verification  HLA-DQA1  KIR  • HLA-A, -B, -DRB1  Class I and II antibody ID - High Res (SAB)* UNRELATED Initial Workup  Other  • HLA-A, -B, -C, -DRB1, -DQBI • Store specimen  HLA-DPB1

Transfusion Support  Class I antibody ID - High Res (SAB)*  HLA-A, -B typing *SAB = Single Antigen Beads

Disease Association/Vaccine: Specify Single Antigen(s)

Date/Time Received: Michigan Blood ID No.:

MICHIGAN BLOOD 26643 1/1/16 Page 1 of 2 HUMAN LEUKOCYTE ANTIGEN (HLA) TESTING COLLECTION OF WHOLE BLOOD SPECIMENS

 Specimen HLA Typing:

6 ml EDTA tube (purple or pink top, depending upon manufacturer) or 6 ml ACD solution B tube (yellow top) or 6 buccal swabs

Contact HLA Laboratory for pediatric drawing requirements or low white count (<1.0) specimen requirements.

Antibody ID – High Res (SAB):

Preferred Specimen: 6 ml tube without anticoagulant (red top, serum separator tubes are NOT acceptable) or 6 ml EDTA tube (purple or pink top, depending upon manufacturer) Blood may be spun and only the serum/plasma submitted

 Labeling Patient’s name and/or other unique identification number and date of collection. Include phlebotomist’s name/initials on Human Leukocyte Antigen (HLA) Testing form.

Samples not properly labeled with be rejected and will have to be redrawn and resubmitted.

 Storage HLA Typing:

Samples can be stored and transported at room temperature (20º-25ºC) or stored and transported frozen.

Antibody ID – High Res (SAB):

Samples can be stored and transported at room temperature (20º-25ºC) for up to 24 hours. After 24 hours, separate serum/plasma, store at 2º-8ºC, and transport on ice.

 Transport As soon as possible after drawing, transport sample and completed Human Leukocyte (HLA) Testing form in accordance with untested or tested positive sample biohazard precautions, as applicable.

MEDICARE (OUTPATIENT) AND MEDICAID BILLING INFORMATION Michigan Blood will bill the institution directly unless testing is performed on an OUTPATIENT Medicare enrollee or a Medicaid recipient from MI. Medicare # Medicaid # Patient’s Address

City State_ Zip Diagnosis ICD9 Dx Code NPI # Referring Physician’s Full Name Referring Physician’s Provider # (NPI#) Physician’s Phone Number

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