We are experiencing exceptionally high volumes in our emergency rooms.
Every patient is important to us, and we are doing all we can to provide care quickly and efficiently.

Bilirubin

Laboratory : Chemistry

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. Bilirubin
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

BILI MACH3

Specimen Type:

Blood

Tube Type:

Green top ( lithium heparin ) tube

Collection Volume:

Collect 1.5 mL

Cause for Rejection:

Hemolysis, lipemia, specimen exposed to light

Storage:

Refrigerated

Availability:

Daily, 24 hours; STAT

Methodology:

Diazo Method

Special Instructions:

Protect the specimen from light exposure. Ask that the bilirubin lights in the NICU be turned off while collecting.

Lab/Phone:

330-746-9623

TAT:

1 hour

Additional Info:

Reference range is age dependent; available on patient report

CPT Code:

82248 and 82247

Panel Includes:

Total and Direct Bilirubin

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