Centralized Core Laboratory - Mayo Clinic Laboratories :
Send Out
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 Be Antigen
2.
3.
4.
5.
6.
SPECIMEN INFO
Collection Date & Time:
Collected By:
Hospital:
Test ID :
HEPBE
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Gold top SST (serum separator tube, no anticoagulant)
Collection Volume:
2.5 mL (minimum 1.5 mL)
Cause for Rejection:
Red Top Tube is NOT acceptable.
Grossly hemolyzed, grossly lipemic, or grossly icteric.
Storage:
Frozen
Availability:
Sent to reference lab
Methodology:
Chemiluminescence Immunoassay (CIA)
Special Instructions:
Remove serum from gel within 2 hours.
Test should be preceded by a HBs Ag Assay which is repeatedly reactive.
Days Performed: MonSat
If collected at an offsite location, send by a STAT Courier to Hospital lab
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range: Negative
CPT Code:
87350
Hepatitis Be Antigen
Test ID/Workstation :
HEPBE
Specimen Type:
Blood
Tube Type:
Gold top SST (serum separator tube, no anticoagulant)
Collection Volume:
2.5 mL (minimum 1.5 mL)
Cause for Rejection:
Red Top Tube is NOT acceptable.
Grossly hemolyzed, grossly lipemic, or grossly icteric.
Storage:
Frozen
Availability:
Sent to reference lab
Methodology:
Chemiluminescence Immunoassay (CIA)
Special Instructions:
Remove serum from gel within 2 hours.
Test should be preceded by a HBs Ag Assay which is repeatedly reactive.
Days Performed: MonSat
If collected at an offsite location, send by a STAT Courier to Hospital lab
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range: Negative
CPT Code:
87350
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