Hepatitis Acute 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. Hepatitis Acute Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

HACTP E8011

Specimen Type:

Blood

Tube Type:

Gold top SST (serum separator tube,no anticoagulant)

Collection Volume:

7.5 mL (minimum 5.0 mL)

Storage:

Shipping- Send Refrigerated; Storage-Refrigerated: 6 days; Frozen: 3 months

Availability:

24 hours/day, 7 days/week

Methodology:

See Individual tests

Special Instructions:

If Hepatitis C Antibody is positive, a confirmatory test will be performed. If the Hepatitis B Surface Antigen is initially reactive, a confirming test will be performed at an additional cost. If confirmatory testing is required, SST serum is the only acceptable specimen type.

Lab/Phone:

330-543-8417

Additional Info:

Reference range: Non-Reactive

CPT Code:

80074

Panel Includes:

Hep Bs Ag; Hep B Core Ab, IgM; Hep A Ab, IgM; Hep C Ab