Mold IV Allergen Panel

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. Mold IV Allergen Panel
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

MOLD

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Collection Volume:

6.0 mL

Minimum Volume:

4.0 ml

Storage:

Refrigerated

Availability:

Sent to Mayo Medical Laboratory

Methodology:

Fluorescence Enzyne Immunoassay ( FEIA)

Lab/Phone:

330-543-8418

TAT:

1-3 days

Additional Info:

Reference range is available on patient report

CPT Code:

86003

Profile Includes:

Trichosporon Pllulans IgE, Cephalosporium Acremonium IgE, Mucor IgE, Candida Albicans IgE, Stemphyllium IgE, Trichophyton Rubrum IgE, Phoma Betae IgE, Helminthosporium IgE, Fusarium Moniliforme IgE, Curvularia Lunata IgE, Epicoccum Purpurascens IgE, Rhizopus Nigricans IgE, Alternaria Tenuis IgE, Aspergillus Fumigatus IgE, Cladosporium IgE, Penicillium IgE, Aspergillus niger, IgE

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Mold IV Allergen Panel

Centralized Core Laboratory - Mayo Clinic Laboratories : Send Out

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