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 ANTIGEN (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 antibody 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 cell 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
MICHIGAN BLOOD 26643 1/1/16 Page 2 of 2