Stat Requisition Form
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1Clinic Name:
__________________________________
UNC Hospitals
Address:_______________________________
McLendon Clinical Laboratories
______________________________________
Outreach Services, 1st Floor, East Wing
Phone#:___________________
Chapel Hill, NC 27514
Fax#:_____________________
(888) 741-5227 or (984) 974-2361
Clinic code: 900
Outreach Location: ________________
(984) 974-1680 (fax)
____________________________
_____________
Patient’s Full Name
Date of Birth:
Sex:_____
(Please Print)
Last
First
Middle / Maiden
____ ___ ____ ____
___________________ - ___
Social Security #
UNC Medical Record #
Last 4 digits only
Billing
Option:
Medicare Part A - Bill Acct # _______
Medicare Part B - Bill Medicare
Patient Insurance
*Call STAT results to:_____________ and give results to physician or patient’s nurse.
STAT
McLendon Laboratories’ Policy requires that critical values be called to the ordering physician or designee.
Dr. ________________________________
*Pager #_________________
(Ordering Provider last name, first name & MI)
Collection Date:_____________Time:________
am / pm
NPI#______________________________________
contact name/#________________
Collected By :___________________________________
____________________________
____
Ordering MD signature
date/time:
NPI required for all Non-UNC Physicians Documentation of verbal orders will be required by audit
*Required-Diagnosis (ICD-10) code(s):
1)____________
2)____________ 3)____________
4)____________ 5)_____________ 6)____________
Medicare will only pay for services that it determines to be reasonable and necessary under section 1862 (a)(1) of the Medicare Law. When ordering tests for which Medicare reimbursement will be
sought, physicians should order only those individual tests that are necessary for the diagnosis and treatment of a patient, rather than for screening purposes.
It is the responsibility of the facility to provide proper documentation for physician orders upon request.
Gold-SST
**ALL TESTS PERFORMED ON
UNLESS OTHERWISE INDICATED.
Chemistry / Hematology / Coagulation / Urinalysis Tests
1
Sodium
40
Uric Acid
2010
CBC
Lav
2
Potassium
23
Magnesium
1735
Pro BNP
2000
CBC/Diff
Lav
3
Chloride
22
Phosphorus
286
Rheumatoid Factor (RF)
2280
Reticulocyte Count Lav
4
CO
196
LD
9563
Vancomycin,
RB
2175
Sed. Rate (ESR)
Lav
Trough
2
38
GGT
9562
Vancomycin,
RB
Must be submitted to UNC
Peak
Electrolyte Panel
within 8 hours of collection.
67
Bilirubin, Direct
9564
Vancomycin,
RB
Random
7454
Hemoglobin A1C
Lav
(all tests above)
68
Bilirubin, total
265
Cyclosporine, Trough
Lav
5
BUN (Urea Nitrogen)
*3008
PT with(INR)
LB
49
Amylase
275
Tacrolimus, Trough
Lav
6
Creatinine
*3020
PTT (APTT)
LB
48
Lipase
713
HCG (Beta-Quant)
9
Glucose
*
Must be submitted to UNC
1064
Lipid Panel, Fasting
716
Estradiol
Redtop
10
Gluocse - Fasting
within 2 hours of collection.
Cholesterol, HDL Chol, Trig, LDLC
1711
T3, free
2600
Urinalysis
20
Calcium
1084
Lipid Panel,
Non-fasting
1707
T3, Total
Must be submitted to UNC
Cholesterol, HDL Chol
Basic Metabolic Panel
706
T4, Free
within 6 hours of collection.
61
Cholesterol
fasting
1327
Urine Microalbumin and
1791
TSH
(all tests above )
65
Triglycerides
24
Total Protein
creatinine ratio
852
Vitamin B12
1147
Iron Profile
25
Albumin
1122
Serum Protein electroph
1360
Vitamin D, 25OH
Iron, Transferrin, TIBC, % Sat
68
Bilirubin, Total
1123
Urine Protein electroph
71
Iron, Total
853
Folate
33
AST
1769
Ferritin
714
PSA, Screening
34
ALT
refer to Mclendon webpage:
150
Digoxin
RB
(undiagnosed,asymptomatic)
715
PSA, Diagnostic
37
ALP
80
Phenobarbital
RB
(patient management/prostatic malignancies)
**Non-spun bloods must be
Comprehensive Panel
103
Phenytoin
RB
(Dilantin)
76
Lead
Tan
received in lab within 2 hours
fasting
Other:_________________
(all tests above )
Immunology/Microbiology
8302
Anti-HAV IgM (Hepatitis A Viral Antibody IgM)
9560
Rapid Group A Strep Test
Room Temp
8310
Anti-HBc IgM (Hepatitis B Core Antibody IgM)
9514
Group A Strep Culture, Throat
Room Temp
8325
Anti-HCV (Hepatitis C Antibody)
9551
Culture, Beta Strep (Group B) (site_________) Room Temp
8320
HbSAg (Hepatitis B Surface Antigen)
9500
Culture, Blood-Routine (site_______________) Room Temp
9057
Anti-Nuclear Ab (ANA)
9517
Culture, Sputum
Room Temp
8212
HIV Ag/AB Screen
9520
Culture, Urine ___ (clean catch) ___ (catheter) Refrigerate
9068
RPR,serum
Culture, Wound (site____________________) Room Temp
8322
Rubella IgG
9225
GI Pathogen panel, stool
Room Temp
7998
CCP antibodies, serum
(place stool in parapak carey-blair media – orange cap)
9800
Stool, O & P Comprehensive (see manual)
Room Temp
9386
Rapid RSV, FLU PCR (NP flocked swab)
see website
9240
Stool, Fecal Lactoferrin
Room Temp
9170
Clostridium Difficile antigen Assay
(submit fresh stool in sterile cup)
For lab use only:
___SST
___LAV
___LB
___RED
___RB
___TAN
___GR
___YEL
___URINE
___SWAB
___GC Culture
___Pap
HD 5530 Rev 10-2015
Chart Location: Provider Orders
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