Hepatitis Be Antigen
| 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. Hepatitis Be Antigen | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
HEPBE
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Gold top SST (serum separator tube, no anticoagulant)
Collection Volume:
2.5 mL (minimum 1.5 mL)
Cause for Rejection:
Red Top Tube is NOT acceptable.
Grossly hemolyzed, grossly lipemic, or grossly icteric.
Storage:
Frozen
Availability:
Sent to reference lab
Methodology:
Chemiluminescence Immunoassay (CIA)
Special Instructions:
Remove serum from gel within 2 hours.
Test should be preceded by a HBs Ag Assay which is repeatedly reactive.
Days Performed: MonSat
If collected at an offsite location, send by a STAT Courier to Hospital lab
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range: Negative
CPT Code:
87350
