CKMB (Total CK and %CKMB)

Centralized Core Laboratory - Summa Akron City Hospital : Send Out

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. CKMB (Total CK and %CKMB)
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

ZMSO

Test Workstation :

SUMMA

Specimen Type:

Blood

Tube Type:

Green top (Lithium heparin)

Collection Volume:

3.0 mL

Minimum Volume:

1.5 mL

Cause for Rejection:

Hemolysis

Storage:

Refrigerated

Availability:

Sendout to SUMMA

Methodology:

Enzyme Immunoassay

Lab/Phone:

330-543-8418

Additional Info:

Reference Range is available on patient report

CPT Code:

82550

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CKMB (Total CK and %CKMB)

Centralized Core Laboratory - Summa Akron City Hospital : Send Out

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