Hepatic Panel

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. Hepatic Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Test ID/Workstation :

LIVER ACHM1

Specimen Type:

Blood

Tube Type:

Green top (lithium heparin) tube

Collection Volume:

1.5mL

Cause for Rejection:

Hemolysis

Storage:

Refrigerated

Availability:

Daily, 24 hours; STAT

Methodology:

See individual tests

Special Instructions:

Protect the specimen from light exposure. Ask that the blue bilirubin lights in the NICU be turned off while collecting.

Lab/Phone:

330-543-8417

TAT:

1 hour

Additional Info:

Reference ranges available under individual tests

CPT Code:

80076

Panel Includes:

Conjugated Bilirubin, Total Bilirubin, ALT, AST, Alkaline Phosphatase, Total Protein, Albumin

Synonyms:

Liver Function Test

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Hepatic Panel

Centralized Core Laboratory : Chemistry

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