HLA-B27

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. HLA-B27
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

HLB27 / DNA1

Specimen Type:

Blood

Tube Type:

Lavender top (EDTA) tube: Whole Blood

Collection Volume:

3.0 mL (minimum 1.0 mL)

Storage:

Refrigerated

Availability:

M-F

Methodology:

Polymerase Chain Reaction (PCR)

Lab/Phone:

330-543-8722

TAT:

3-7 days

Additional Info:

Reference range: Negative for HLA-B27

CPT Code:

81374

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HLA-B27

Molecular Diagnostics : DNA

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