BCR/ABL, mRNA Detection
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. BCR/ABL, mRNA Detection | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
BCRQ
Test Workstation :
MAYO
Specimen Type:
Whole Blood or Bone Marrow
Tube Type:
Purple top (EDTA)tube
Collection Volume:
10.0 mL Whole Blood; 4.0 mL Bone Marrow
Minimum Volume:
8.0 ml Blood, or 2 mL Bone Marrow
Cause for Rejection:
Specimen must arrive within 72 hours of collection
Storage:
Refrigerated
Availability:
Mon-Fri; 2 p.m.
Methodology:
Reverse Transcription-Polymerase Chain Reaction (RT-PCR) with Fluorescent-Bead array Analysis
Special Instructions:
The following information is required:
1. Pertinent clinical historyconfirm that this test is being used for the purpose of making an initial diagnosis
2. Date of Collection
3. Specimen source (blood or bone marrow)
For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly)
Lab/Phone:
330-543-8418
TAT:
5-10 days
CPT Code:
81206, 81207 and 81208
