Cordstat Drug Screen
| 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. Cordstat Drug Screen | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
CORDD
Test Workstation :
USDTL
Specimen Type:
Umbilical cord tissue
Tube Type:
Kit provided by USDTL Laboratory for specimen and requisition
Collection Volume:
6 inches umbilical cord tissue
Cause for Rejection:
Umbilical cord rinsed with alcohol or fixed with formalin
Storage:
Ambient
Availability:
Sent to Reference Laboratory
Special Instructions:
Sample size is 6 inches of umbilical cord tissue that has been drained, exterior rinsed with saline (NO alcohol product), Â and patted dry.
Umbilical cord is NOT fixed in formalin.
TAT:
2-3 days
Additional Info:
Umbilical cord is stored at room temperature for 7days, can be refrigerated (2-8 degrees C) for up to 3 weeks and frozen (<10 degrees C) up to 1 year.
CPT Code:
80301
