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. Homocysteine, Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Homocysteine, Urine
CPT Code: 83090

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 4.0 mL (minimum 2.5 mL) random urine

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) Stable Isotope Dilution Analysis

Special Instructions: Have patient fast overnight and discard first morning urine specimen. Have patient continue to fast and collect next random specimen. Place on ice and deliver to lab promptly. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 0-9 mcmol/gram of creatinine

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: