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TSH with reflex T4FR

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. TSH with reflex T4FR
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

TSHR E8011

Specimen Type:

Blood

Tube Type:

Green top (lithium heparin) tube

Collection Volume:

2.0 mL (minimum 1.5 mL)

Storage:

Shipping- Send Refrigerated; Storage- Room Temp: 5 days; Refrigerated: 7 days; Frozen: 30 days

Availability:

24 hours/day, 7 days/week

Methodology:

Roche-ECLIA

Lab/Phone:

330-543-8417

TAT:

4 hours

Additional Info:

Reference range is age dependent, available on patient report

CPT Code:

84443, if reflexed 84439

Panel Includes:

TSH with reflex to T4FR

Synonyms:

Thyroid Stim Hormone; Thryotropin (Stim) Hormone

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