CMV PCR with Reflex to Quantitative PCR

Molecular Diagnostics : DNA

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. CMV PCR with Reflex to Quantitative PCR
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

CMVPR DNA2

Specimen Type:

Plasma

Tube Type:

Purple top (EDTA) tube

Collection Volume:

2.5 mL blood

Cause for Rejection:

QNS

Storage:

Refrigerated

Methodology:

Real-time Polymerase Chain Reaction (PCR)

Special Instructions:

Centrifuge purple top tube promptly and send 1.0 mL (minimum 0.5 mL) plasma or amniotic fluid, refrigerated. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

Lab/Phone:

330-543-8722

TAT:

1-3 days

Additional Info:

If positive, Qualitative test will be cancelled and Quantitative test will be ordered and resulted.

CPT Code:

87496 (if Qualitative); 87497 (if Quantitative reported)

Synonyms:

Cytomegalovirus DNA

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Laboratory Services

CMV PCR with Reflex to Quantitative PCR

Molecular Diagnostics : DNA

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