Clostridium difficile by Amplification

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. Clostridium difficile by Amplification
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

CDIFA

Test Workstation :

MIC2

Specimen Type:

250mg (pea sized amount) of soft stool or 0.5 mL liquid stool in sterile container.

Cause for Rejection:

Formed stool, stool specimen sent on swab, diaper, or dried applicator stick, stool sent in viral transport media, stool in CaryBlair.

Storage:

Refrigerated at 2-8C for <24 hours.

Availability:

Mon-Sun (0700-1600)

Methodology:

Nucleic acid amplification test for the detection of C. difficile toxin A/B.

Lab/Phone:

330-543-4863

TAT:

48 hours

CPT Code:

87493

Synonyms:

Stool for C. diff Toxin, Cl. difficile Toxin Assay, C. difficile