Hereditary Hemochromatosis DNA Test
| 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. Hereditary Hemochromatosis DNA Test | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
HFET
Test Workstation :
MAYO
Specimen Type:
Whole Blood
Tube Type:
Purple top (EDTA) tube: Whole Blood
Alternate Tube Type:
ACD or any anticoagulant tube
Collection Volume:
2.5 mL (minimum 0.5 mL)
Storage:
Ambient
Availability:
Sent to Reference Laboratory
Methodology:
Droplet Digital Polymerase Chain Reaction (ddPCR) used to test for 3 mutations in the HFE gene: C282Y,H63D,S65C
Special Instructions:
Molecular Genetics: Congenital Inherited Diseases Patient Information (T521) in Special Instructions.
For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).
Lab/Phone:
330-543-8418
TAT:
6-7 days
Additional Info:
Reference range is available on patient report
CPT Code:
81256
