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. Insulin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Insulin
CPT Code: 83525

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant)

Collection Volume: 3.0 mL(minimum 1.5 mL)

Cause for rejection: Hemolysis, EDTA plasma is not suitable for use. Sodium fluoride causes a decrease in values.

Storage: Frozen

Availability: Mon, Weds, Fri (0800-1600)

Methodology: Chemiluminescent Assay

Special Instructions: Specimen must be in the laboratory by 1300 for same day results.

TAT: 3 hours


Lab/Phone: 330-543-8484

Additional Info: Reference range: Post 4-12 HR Fast 0-8 Years: 0-13 uIU/mL > 8 Years: 0-17 uIU/mL 2 HR Post Meal: 7.6-26 uIU/mL 2 HR Post Glucose Testing: 15-53 uIU/mL

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: