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SC5b-9

Laboratory : Hematology

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. SC5b-9
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

SC5B9/CINCI

Specimen Type:

Whole Blood

Tube Type:

Purple Top (EDTA)

Collection Volume:

3.0 mL(minimum 1.0 mL)

Cause for Rejection:

Incorrect anticoagulant, Hemolyzed, clotted, or older than 2 hours unspun.

Storage:

Send to lab at Room Temperature

Availability:

Sent to Reference Laboratory

Methodology:

Enzyme immunoassay (EIA)

Special Instructions:

Whole blood stable for 2 hours at room temperature. Can only be drawn at Akron or Mahoning Valley Hospital. Lab-Minimum for testing: 0.5 mL plasma in one aliquot, frozen within 2 hours of collection. Two 0.5ml plasma aliquots preferred. Ship frozen plasma on dry ice.

Lab/Phone:

330-543-8418

TAT:

4-7 days

CPT Code:

86160

Synonyms:

MAC (SC5b-9) Eculizumab Monitor (SC5b-9) Membrane Attack Complex (SC5b-9) Soluble Terminal Complement Complex (SC5b-9)

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