Lyme Disease Serology

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. Lyme Disease Serology
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

LYMSR

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top tube-Serum

Collection Volume:

1.5 mL (minimum 1.0 mL)

Cause for Rejection:

Grossly hemolyzed, grossly lipemic

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Enzyme Linked Immunosorbent Assay (ELISA)

Lab/Phone:

330-543-8148

TAT:

1-4 days

Additional Info:

NOTE: If Lyme Disease Serology is positive, then Lyme Disease Antibody Confirmation by Western blot will be performed at an additional charge.

CPT Code:

86618, (86617x2 if Western blot performed)

Synonyms:

Borrelia Burgdorferi

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Lyme Disease Serology

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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