Medical Neurogenetics Misc. Sendout

Centralized Core Laboratory : Chemistry

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. Medical Neurogenetics Misc. Sendout
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3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

MNGM/Mayo

Specimen Type:

Cerebrospinal Fluid

Tube Type:

Medical Neurogenetics Collection kit

Collection Volume:

Collect 4.5 ml CSF- Medical Neurogenetics collection kit required.

Storage:

Frozen

Availability:

Sent to Medical Neurogenetics Lab via Mayo Medical Laboratories

Methodology:

Varies depending on test ordered.

Special Instructions:

Call Centralized Core Lab (ext. 38418) to obtain kit. Complete Medical Neurogenetics, LLC request form, include sample date and date of birth. Collected CSF can be shared between multiple Medical Neurogenetics Sendout tests.

Lab/Phone:

330-543-8418

TAT:

10-14 days

Additional Info:

Providers can choose from the following tests: 1. Neopterin, CSF (Methodology: HPLC/Electrochemistry/Fluorescence) 2. Sialic Acid, CSF (Methodology: LC/MS/MS) 3. Alpha-Aminoadipic Semialdehyde, CSF (Methodology LC/MS/MS) Choose one test order per Sendout order; collected CSF can be shared between multiple Medical Neurogenetic tests above.

CPT Code:

Neopterin CPT Code 82542; Sialic Acid CPT Code 84275; Alpha-Aminoadipic Semialdehyde CPT Code 84275