Lipoprotein Electrophoresis
| 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. Lipoprotein Electrophoresis | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
LIPEL
Test Workstation :
CLEVE
Specimen Type:
Blood
Tube Type:
Gold top SST (serum separator tube, no anticoagulant)
Alternate Tube Type:
Red Top Serum
Collection Volume:
2.5 mL
Minimum Volume:
1.5 mL
Cause for Rejection:
Heparin, body fluids, and frozen samples
Storage:
Ambient- after separation from cells:1 day; Refrigerated-after separation from cells: 7 days; Frozen: Unacceptable
Availability:
Sent to reference lab
Methodology:
Electrophoresis, Enzymatic, Detergent solubilization
Special Instructions:
Patient should fast for 1215 hours. If lipid results are not provided, lipid profile will be ordered and charged separately. Results for total cholesterol, triglycerides, LDL, VLDL, and HDL may be included on requisition.
Lab/Phone:
330-543-8418
TAT:
2-9 days
Additional Info:
Reference range is available on patient report
Days Performed: Thur
CPT Code:
83700, 80061
Panel Includes:
Cholesterol; Triglycerides; HDL Cholesterol; LDL Cholesterol; VLDL Cholesterol(calculated); Appearance; Lipoprotein Electrophoresis
