Anti-Neutrophil Cytoplasmic Antibody

Infectious Disease Laboratories : Immunology

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. Anti-Neutrophil Cytoplasmic Antibody
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

ANCAB MAYO

Specimen Type:

Blood

Tube Type:

Gold top SST ( Serum Separator) tube

Collection Volume:

2.0 mL (minimum 1.0 mL)

Storage:

Refrigerated

Availability:

Sent to Reference Laboratory

Methodology:

Indirect Immunofluorescence (IFA)

Special Instructions:

Days Performed: Mon-Sat

Lab/Phone:

330-543-8418

TAT:

2-4 days

Additional Info:

Reference range: Negative

CPT Code:

86255, (plus 86256 Titer, if appropriate)

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