Hemoglobin A1c
| 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. Hemoglobin A1c | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
HBA1C
Test Workstation :
ACHM5
Specimen Type:
Blood
Tube Type:
Purple top (EDTA) tube: Whole Blood
Minimum Volume:
500 uL
Preferred Volume:
2 mL
Storage:
Shipping- Send Refrigerated; Storage- Room Temp: 3 days; Refrigerated: 7 days; Frozen: 6 months
Availability:
24 hours/day, 7 days/week
Methodology:
Roche-TINA-Quant
Special Instructions:
Do not spin, whole blood sample required.
Lab/Phone:
330-543-8418
TAT:
4 hours
Additional Info:
Reference range is available on patient report
CPT Code:
83036
Synonyms:
Glycosylated Hemoglobin; GHB; Fast Hemoglobin
