HIV 1&2 Antibody Screen

Infectious Disease Laboratories : Immunology

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. HIV 1&2 Antibody Screen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

HIV12 MAYO

Specimen Type:

Blood

Tube Type:

Purple top (EDTA) tube

Collection Volume:

15.0 mL (minimum 3.0 mL)

Cause for Rejection:

Grossly, hemolyzed, grossly lipemic, grossly icteric or Autopsy or cadaver blood specimens

Storage:

Refrigerated

Availability:

Sent to Reference Laboratory

Methodology:

Chemiluminescent Microparticle Immunoassay

Special Instructions:

Spin down and remove plasma

Lab/Phone:

330-543-8418

TAT:

1-2 days

Additional Info:

Reference range: Negative

CPT Code:

87389

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Laboratory Services

HIV 1&2 Antibody Screen

Infectious Disease Laboratories : Immunology

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