Hemoglobin A1c

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. Hemoglobin A1c
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

HBA1C ACHM5

Specimen Type:

Blood

Tube Type:

Purple top (EDTA) tube: Whole Blood

Collection Volume:

2.0 mL (minimum 0.5 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

Lab/Phone:

330-543-8419

TAT:

4 hours

Additional Info:

Reference range is available on patient report

CPT Code:

83036

Synonyms:

Glycosylated Hemoglobin; GHB; Fast Hemoglobins

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