State Metabolic Screen

Centralized Core Laboratory - Ohio Department of Health : 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. State Metabolic Screen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

NBSCN

Test Workstation :

OHIO

Specimen Type:

Blood

Collection Volume:

Five blood soaked circles on special filter paper

Cause for Rejection:

Clotted; filter paper not thoroughly saturated; layering of blood,

Storage:

Ambient

Availability:

Sent to reference lab

Methodology:

Tandem Mass Spectrophotometry/ Isoelectric Focusing/ Wallac

Special Instructions:

Allow a large drop of blood to fall on filter paper, soaking through to opposite side.

Lab/Phone:

330-543-8418

TAT:

7-21 days

Additional Info:

Reference range is available on patient report

CPT Code:

84443, 83789, 83516, 82776, 83498, 82261, 83020

Panel Includes:

See the ODH Newborn screening website for tests contained in the panel

Synonyms:

Phenylketonuria, PKU Card, ODH Card

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State Metabolic Screen

Centralized Core Laboratory - Ohio Department of Health : Send Out

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