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 Panel: APC Resistance, Antithrombin 3, Protein C, Protein S, functional - if abnormal in the panel. For additional qualitative evaluation reflex to Protein S, free and total Antigen of opiate exposure, please contact the Laboratory (688-2444). vWD Panel: vWFAg, Ristocetin Cofactor, F VIII activity • More comprehensive toxicology testing services Coagulation factors available are Factors XI , IX , VII, V , II , X , XII are available. For additional information, please Blood Parasites: Malaria (PMAL), Babesia (PBAB), Ehrlichia (PEHR), includes smear review †† contact the Laboratory (688-2444). • No chain of custody provided, results are intended for medical purposes only.

(2) HIV RNA (ultrasensitive)

• Use if patient on treatment and standard PCR <400 copies