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. Adrenocorticotropic Hormone   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Adrenocorticotropic Hormone
CPT Code: 82024

Specimen Type: Plasma

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 2.5 mL (minimum 1.25 mL)

Storage: Frozen

Availability: Sent to reference lab

Methodology: Electrochemiluminescence Immunoassay

Special Instructions: Collect on Ice. Spin down in a refrigerated centrifuge and immediately separate plasma from cells. Morning (6 a.m. -10:30 a.m.) specimen is desirable. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly)

TAT: 1-2 days


Lab/Phone: 330-543-8418

Additional Info: Reference Range: 7.2-63 pg/mL (a.m. draws) No established reference range for p.m. draws. Pediatric reference values are the same as adults, as confirmed by peer reviewed literature.

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: