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, Total

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, Total
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

TBILI MACH3

Specimen Type:

Blood

Tube Type:

Green top (lithium heparin) tube

Collection Volume:

1.5 mL

Storage:

Shipping: Refrigerated (protect from light); Storage Room Temp: 1 day; Refrig: 7 days; Frozen: 6 months **if protected from light)

Availability:

24 Hours/day, 7 days/week

Methodology:

Roche-Diazo Method

Special Instructions:

Protect 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:

82247

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