HIV 1 and 2 Ag and Ab Screen

Centralized Core Laboratory - : Chemistry

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 and 2 Ag and Ab Screen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

HIVD

Test Workstation :

E8011

Specimen Type:

Blood

Tube Type:

Purple top (EDTA) tube

Collection Volume:

10.0 mL (minimum 3.0 mL)

Minimum Volume:

1.5 mL (3 mL if confirmatory testing is required.)

Preferred Volume:

3 mL

Storage:

Shipping- Send Refrigerated; Storage- Room Temp: 7 days; Refrigerated: 4 weeks; Frozen: 3 months

Availability:

24 hours/day, 7 days/week

Methodology:

Roche- Electrochemiluminescence Immunoassay sandwich principle

Special Instructions:

Initially Reactive specimens will be sent out for supplemental HIV Antibody Confirmation/ Differentiation testing. If confirmatory testing is required, EDTA plasma is the only acceptable specimen type.

Lab/Phone:

330-543-8418

TAT:

4 hours

Additional Info:

Reference range: Non-Reactive

CPT Code:

87389

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HIV 1 and 2 Ag and Ab Screen

Centralized Core Laboratory - : Chemistry

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