Thyroid Stimulating Immunoglobulin

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. Thyroid Stimulating Immunoglobulin
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

TSI

Test Workstation :

MAYO

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube

Alternate Tube Type:

SST

Collection Volume:

1.5 mL

Minimum Volume:

0.3 mL

Storage:

Frozen

Availability:

Sent to Reference Laboratory

Methodology:

Recombinant Bioassay

Lab/Phone:

330-543-8418

TAT:

2-6 days

Additional Info:

Reference range available on patient report

CPT Code:

84445

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