Mitochondrial Ab Panel

PATIENT INFO

Patient Name:

Medical Record #:

BD: / / Sex: F M

PHYSICIAN INFO

Physician Name :

Address:

Ph: ( ) - Fax: ( ) -

Additional Report to:

Ph: ( ) - Fax: ( ) -

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

MITO

Test Workstation :

CLEVE

Specimen Type:

Serum

Tube Type:

Gold top (SST) no anticoagulant tube

Collection Volume:

2.5 mL(minimum 1.0 mL)

Storage:

Refrigerated

Availability:

Sent to Reference Laboratory

Methodology:

Indirect Immunofluorescence Assay (IFA)

Special Instructions:

If Mitochondrial Ab Panel is Positive, titer will be performed and billed.

Lab/Phone:

330-543-8418

TAT:

1-4 days

Additional Info:

Reference range: Negative Days Performed: Mon-Fri

CPT Code:

86255