Anti-Neutrophil Cytoplasmic Antibody
| 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. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
ANCAB
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Gold top SST ( Serum Separator) tube
Collection Volume:
2.0 mL
Minimum Volume:
1.0 mL
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Multiplex Flow Immunoassay
Special Instructions:
Days Performed: MonSat
Lab/Phone:
330-543-8418
TAT:
2-4 days
Additional Info:
Reference range: Negative
CPT Code:
86255, (plus 86256 Titer, if appropriate)
