Smooth Muscle Ab

Infectious Disease Laboratories : Immunology

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. Smooth Muscle Ab
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

SMOM MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant)

Collection Volume:

2.0 mL (minimum 1.0 mL )

Cause for Rejection:

Gross hemolysis, gross lipemia

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Indirect Immunofluorescence (IFA)

Special Instructions:

Positive findings will reflex a Smooth Muscle Titer test.

Lab/Phone:

330-543-8418

TAT:

2-4 days

Additional Info:

Reference range: Negative

CPT Code:

86255

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