Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Mitochondrial Ab Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Mitochondrial Ab Panel
CPT Code: 86255

Specimen Type: Serum

Tube Type/Collection Container: Gold top (SST) no anticoagulant tube

Collection Volume: 2.5 mL(minimum 2.0 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.

TAT: 1-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative Days Performed: Mon-Fri

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: