Medical Neurogenetics Misc. Sendout
| 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. Medical Neurogenetics Misc. Sendout | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MNGM
Test Workstation :
MAYO
Specimen Type:
Cerebrospinal Fluid
Tube Type:
Medical Neurogenetics Collection kit
Collection Volume:
Collect 4.5 ml CSF- Medical Neurogenetics collection kit required.
Storage:
Frozen
Availability:
Sent to Medical Neurogenetics Lab via Mayo Medical Laboratories
Methodology:
Varies depending on test ordered.
Special Instructions:
Call Centralized Core Lab (ext. 38418) to obtain kit. Complete Medical Neurogenetics, LLC request form, include sample date and date of birth. Collected CSF can be shared between multiple Medical Neurogenetics Sendout tests.
Lab/Phone:
330-543-8418
TAT:
10-14 days
Additional Info:
Providers can choose from the following tests:
1.Neopterin, CSF (Methodology: HPLC/Electrochemistry/Fluorescence)
2.Sialic Acid, CSF (Methodology: LC/MS/MS)
3.Alpha-Aminoadipic Semialdehyde, CSF (Methodology LC/MS/MS)
Choose one test order per Sendout order; collected CSF can be shared between multiple Medical Neurogenetic tests above.
CPT Code:
Neopterin CPT Code 82542; Sialic Acid CPT Code 84275; Alpha-Aminoadipic Semialdehyde CPT Code 84275
