Plasma Hemoglobin

Centralized Core Laboratory : Hematology

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. Plasma Hemoglobin
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

PLHGB SPHEM

Specimen Type:

Blood

Tube Type:

Purple Top Tube (EDTA)

Collection Volume:

2.5 mL blood purple top (EDTA)tube

Storage:

Refrigerated

Availability:

Daily 24hr; Stat

Methodology:

Hemocue

Special Instructions:

Available on ECMO patients only. Any other requests must have a pathologists approval.

Lab/Phone:

330-543-8416

TAT:

2 hours

Additional Info:

Therapeutic Range for ECMO patient <41 mg/dL

CPT Code:

83051

Synonyms:

Free Hemoglobin; Plasma Free Hemoglobin

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