Lyme Disease, Western Blot (Mayo)

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, Western Blot (Mayo)
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

LYWB

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top tube - serum

Collection Volume:

2.0 mL

Minimum Volume:

1.5 mL

Cause for Rejection:

Specimen rejected; Grossly hemolyzed, grossly lipemic, grossly icteric

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Immunoblot

Lab/Phone:

330-543-8148

TAT:

1-4 days

CPT Code:

86617x2

Panel Includes:

Lyme IgG W Blot, Lyme IgG Bands, Lyme IgM W Blot, Lyme IgM Bands, Lyme Western Blot Interpretation

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Lyme Disease, Western Blot (Mayo)

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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