Outpatient Laboratory Requisition
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Yale-New Haven Hospital Department of Laboratory Medicine Outpatient Laboratory Requisition 20 York Street, New Haven, Connecticut 06510-3202 · 203-688-3670 · 1-800-305-3278 DATE: _____/____/_____ Unit #___________________________ Visit #_______________________________ Patient Name _______________________________________________________________________________ (Last, First, Middle Initial) Date of Birth______/_____/______ ❑ Female ❑ Male Patient Telephone: (______) ________-_____________ Address ___________________________________________________________________________________ (Street, City, State, Zip) ❑ Mr. Insured’s Name ❑ M r s . _______________________________________________________________________ Ms. Insured’s I.D. # __❑____________________________________________________________________________ Payor Number ______________________________________________________________________________ Primary Insurance: Name & State _______________________________________________________________ Relationship to patient: ❑ Self ❑ Spouse ❑ Child ❑ Other __________________________________________ Group # _________________________________ Insured’s Employer ________________________________ Diagnosis / ICD 9 Code _________________________ TIME DRAWN: ________ ❑ YNHH Blood Draw ❑ Fasting Specimen Type: ❑ Blood ❑ Urine ❑ Other_______________________ ❑ CSF ❑ Fluid____________ ❑ Bone Marrow ❑ Call / ❑ Fax Results ❑ Timed Urine Date Collected _______ Time Collected ________ To:________________________________ CC: X TEST NAME SCC CODE X TEST NAME SCC CODE X TEST NAME SCC CODE X TEST NAME SCC CODE PANELS BK Virus DNA PCR (Qual), Urine BKURN HBs Ab HBSAB %Free PSA (inc Total PSA) PSAFG *Any Panel component may be ordered separately BK Virus DNA PCR (Quan), Blood BKVQT HBsAg HBSGG PTT PTT CBC w/ Auto Diff CBCWD Blood Grp & Rh ABORH HCV Ab HCVAB Reticulocyte RETIC Electrolyte Panel LYTES Bone Marrow Stain BMASP HCV Quantitative PCR HCVQP Rheumatoid Factor RF Na,K,Cl,CO2 Bone Marrow Stain, Iron BMFE hCG, quant HCGQ Ristocetin Cofactor RCF ❑ Hepatic Function HEPAN Bone Marrow Stain Pedi PEDBM HDL Cholesterol HDL Rubella, IgG RUBBG Alb,Globulin,AST, ALT, ALK Phos, Bili T, Bili D, T Protein BUN BUN Hemoglobin Screen HGBSC RVVT DRV ❑ Basic Metabolic BMPOP CA 125 CA125 HIV-1 Ab HIV12 Sirolimus RAPA Na,K,Ca,Cl,CO2,Glucose BUN, Creatinine CA 15.3 CA153 HIV-1 Quantitative PCR HIVQP Tacrolimus TACRO ❑ Comp Metabolic CMPOP Calcium CA *The patient has not refused HIV testing.* Thyroid Indices EFTP Na,K,Cl,CO2,Glucose,Ca,BUN Creatinine,T Protein, Carbamazepine CARBM This box must be checked in order for test to be performed Thyroglobulin Ab ATHYG Alb, Globulin, AST, Alk Phos, Bili T, ALT CEA CEA H. pylori Ab HPYLG Thyroglobulin THYRO ❑ Lipid Panel LIPID Cholesterol CHOL Immunofixation EP IFEP Toxoplasma Ab, IgG TOXOG Chol,Trig,HDL, LDL Calculation CMV ,IgG CMVIG IgE IGE Toxoplasma Ab, IgM TOXOM ❑ Acute Hepatitis Panel HEPAP CMV DNA PCR (Quant), Blood CMVQT IgG IGG TSH, Thyrotropin TSH anti-HAV IgM, anti-HBc total w/reflex, HBsAg w/reflex, anti-HCV CMV, IgM CMVIM IgA IGA Triglycerides TRIG ❑ Chronic Hepatitis Panel HEPCP Cold Agglutinin COLD IgM IGM Uric Acid URIC HBsAg w/ reflex, anti-HBs, anti-HBc total w/reflex, anti-HCV Complement C3 C3 Influenza A RT-PCR w/Subtyping (Swine) FLANP Urinalysis UMAC ❑ Hepatitis B Panel HEPBP Complement C4 C4 Iron, TIBC, %Sat FEPAN Urine Drugs of Abuse UDRGS HBsAg, anti HBc total w/reflex, anti-HBs Cortisol CORT LDH LD VDRL VDRLG ❑ Lupus Anticog Panel LUPUS CPK CK LH LH Vitamin B12 VB12 RVVT, PTT, Phospholipid Neutralization, if PTT abnormal Creatinine CREAT FSH FSH Vitamin D 25-OH VID25 reflex tp Mixing Study C-Reactive Protein(hS) CRP Lipase LIPAS Vitamin D 1,25 di-OH VD125 ❑ Hyper Coag Panel HYPER Cryoglobulin CRYGG Lyme Titer LYME VZV Ab, IgG VZVBG APC Resistance, Antithrombin 3, Protein C, CSF, Cell Count CSFCC Magnesium MG Protein S, functional - if abnormal reflex to Protein S, CSF, Oligoclonal Bands OLIGG Measles IgG MEASG VIROLOGY free and total Antigen Cyclosporin CYCLO Microalbumin(Urine) UALB Respiratory Virus DFA, Nasopharynx RDFNP ❑ VWD Panel VWD D-Dimer DD Monospot(Heterophile) HETER HSV Culture, Dermal HSVCX vWFAg, Ristocetin Cofactor, F VIII activity Digoxin DIG Mycoplasma Ab IgG MYCOG SOURCE:__________________ ALPHABETICAL LIST EBV Panel (Acute) EBVAP Mycoplasma Ab IgM MYCOM MICROBIOLOGY *Any component may be ordered separately EBV Panel (Immune) EBVIP Norovirus Genogroup 1/2 RT-PCR NOROQ SOURCE:__________________ A1C Hemoglobin A1C Erythropoietin EPO Occult Blood, StoolX3 OBLD Bacterial Culture AFP (Tumor Marker) AFPT ESR(Sed Rate) ESR Parvovirus B19 IgG, IgM PB19P Blood Culture CXBLD Alk Phos ALKP Ferritin FERR Phenytoin PHENY Chlamydia DNA Probe PRCHL ALT ALT Fibrinogen FIB Phosphate PHOS GC DNA Probe PRGC Amylase AMYL Fluid Cell Count FCC Platelet Count PLT GC Culture CXGC ANA ANA Folate (Serum) FOL Potassium K Ova & Parasite OPEXM Antibody Screen ABSC Glucose, CSF CGLU Protein,CSF CTP Strep Grp A Rapid Ag AGSTR Anti Platelet Ab IPLT Glucose, Fasting GLUF Protein,EP SPEP Strep Grp B PCR PRGBS Anti DNAse B DNSB Glucose 1HR (Gestational) 1HGTT Protein,Total TP Urine Culture CXURN ASLO ASO Glucose, Random GLUG Protein,Urine UTP AST AST Haptoglobin HAPT PT/INR PTINR Bilirubin, Direct DBIL HAV Ab, Total HAVBT PSA, Total PSA Bilirubin, Total TBIL HAV Ab, IgM HAVMG PSA, Screening PSAS This requisition serves as documentation that these services were ordered by a health care professional authorized to order laboratory tests and are medically necessary. Documentation of medical necessity is contained within the healthcare professional’s patient records. The signature of the ordering healthcare provider and diagnosis information (ICD 9 code or narrative) are REQUIRED. For Placement of Authorizing Physician Signature ____________________________________________________________________ Bar Code Label I authorize YNHH to release information received, including without limitation, medical information, which includes laboratory test results, to my health plan/insurance carrier, and its authorized representatives. I further authorize my health plan/insurance carrier to directly pay Yale-New Haven Hospital for the service rendered. X__________________________________________________________________________________________________________________________ Date________________________ Brian Smith, M.D. Director - CLIA#0700098656 State of CT reg#HP-0211 Medicare only covers services that are reasonable and necessary for the diagnosis and treatment of disease. Routine screening tests are F4950 (Rev 05/10) generally not covered by Medicare. Drawstations Locations Yale Physician’s Building Long Wharf Drawstation Madison Drawstation East Haven Drawstation 800 Howard Avenue 150 Sargent Drive 6 Woodland Road 317 Foxon Rd, East New Haven, CT 06510 New Haven, CT 06511 Madison, CT 06443 Haven, CT 06512 203-688-5006 203-688-1009 203-318-3580 203-466-5550 M-F 7:30 AM - 5:30 PM M-F 8:00 AM - 6:30 PM M-F 7 AM - 4 PM M-F 7 AM - 4 PM Saturday 9 AM - 1 PM Closed Noon - 1 PM Closed 12:30-1:30 PM North Haven Drawstation Hamden Drawstation Branford Draw Station Temple Drawstation Shoreline Medical Center 100 Broadway 2560 Dixwell Ave 11 Harrison Ave 40 Temple Street Drawstation North Haven, CT 06473 Hamden, CT 06514 Branford, Ct 06405 New Haven, CT 06504 111 Goose Lane 203-239-0792 203-230-3300 203-315-2101 203-688-3183 Guilford, CT 06437 M-F 8 AM - 4:30 PM M-F 7 AM-5 PM M-F 7 AM-5 PM M-F 8:30 AM - 5 PM 203-453-7160 Closed from Closed 12:30-1PM Sat 8 AM-12 Noon M-F 7 AM - 5:00 PM Noon - 12:30 PM Saturday 8 AM-Noon Saturday 8 AM - Noon Reflex Testing HBsAg w/ reflex: HBeAg and anti-HBe done if HBsAg positive to assess infectivity. Anti-HBc total done if HBsAg positive to confirm specificity. Neutralization of positive samples done if necessary (i.e. first positive, low positive, and/or anti-HBc total negative) anti-HBc total w/ reflex: anti-HBc IgM done if anti-HBc total positive HCV Ab w/reflex: HCV RIBA done if HCV EIA low positive. HSV/VZV DFA w/ reflex culture: Culture done if DFA negative CBC / differential reflex: Manual differential / smear review done for abnormal CBC Definition of Panels (1) Urine Toxicology Notes Electrolyte Panel: Na,K,Cl,CO2 Hepatic Function: Alb,Globulin,AST, ALT, ALK,Phos, Bili T, Bili D, T Protein • Requires 30 ml of urine Basic Metabolic: Na,K,Ca,Cl,CO2, Glucose BUN, Creatinine • Urine Drugs of Abuse Panel: Amphetamine group*, Barbiturates*, Benzodiazapines, Cocaine Comp Metabolic: Na,K,Cl,CO2, Glucose,Ca, BUN,Creatinine,T Protein, Alb, Globulin, AST, Alk Phos, Metabolites*, Methadone*, Opiates* †, Oxycodone Bili T, ALT and PCP*. Lipid Panel: Chol,Trig,HDL, LDL Calculation * Positive results of these drugs are confirmed Acute Hepatitis Panel: anti-HAV IgM, anti-HBc total w/reflex, HBsAg w/reflex, anti-HCV by additional testing. If confirmation of benzodi- azepines is desired, please contact the Labora- Chronic Hepatitis Panel: HBsAg w/ reflex, anti-HBs,anti-HBc total w/reflex, anti-HCV tory (688-2444). Hepatitis B Panel: HBsAg, anti HBc total w/reflex, anti-HBs † Opiate assay detects morphine and codeine with high sensitivity but does not routinely detect Lupus Anticoqulant Panel: RVVT, PTT, Phospholipid Neutralization, if PTT abnormal reflex tp therapeutic levels of oxycodone. However, a sensi- Mixing Study tive and specific assay for oxycodone is included Hypercoagulable