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. Hepatitis B Surface Ab   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hepatitis B Surface Ab
CPT Code: 86706

Specimen Type: Blood

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

Collection Volume: 3.0 mL (minimum 1.5 mL)

Cause for rejection: Red Top Tube is NOT acceptable.

Storage: Frozen

Availability: Sent to reference lab

Methodology: Chemiluminescence assay

Special Instructions: Spin down and remove serum from clot within 24 hours If collected at an offsite location, send by a STAT Courier to Hospital lab

TAT: 1-2 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Qualitative: Unvaccinated-Negative; Vaccinated-Positive Quantitative results: Unvaccinated-<5.0; Vaccinated: > or = 12.0 This assay provides both qualitative and quantitative results

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: