Lab Outpatient Order Form Camc printable pdf download

Charleston Area

*6163*

Medical Center

Charleston, West Virginia

PLACE

LAB OUTPATIENT ORDER FORM

PATIENT IDENTIFICATION LABEL

HERE

General FAX 304-388-7615

Memorial FAX 304-388-9525 Phone 304-388-4190

Women and Children’s FAX 304-388-2736

Name:_____________________________________________ Phone:__________________ Date/Time: ___________

Date of Birth:___________________ SS #:______________________ Sex:  M

 F

Fasting :  Yes

 No

Date Collected: ______________Time Collected: ___________ Collected By: ______________Priority: ____________

SPECIAL PROFILES

CPT

LABORATORY

CPT

LABORATORY

CPT

 PROSTATE SPECIFIC ANTIGEN DIAG

  B ASIC METABOLIC PANEL

(BSMBP) 80048  ESTRADIOL

(ESTD)

82670

84153

(PSA)

 COMPREHENSIVE METABOLIC PANEL

 PROSTATE SPECIFIC ANTIGEN

G-

80053  EPSTEIN BARR VIRUS PANEL

(EBVS)

(CPMBP)

SCREEN

(PSAAS)

0103

 ELECTROLYTE PANEL

(ELEC) 80051  EB VCA IgG

(VGAG)

86665  PT (PROTHROMBIN TIME)

(IPTR)

85610

 HEPATIC FUNCTION PANEL

(HEPAN)

80076  EB VCA IgM

(VGAM)

86665  RETIC COUNT

(RETC)

85045

 RF **

 LIPID PANEL

(LIPDP) 80061  EBNA

(EBNA)

86664

86430

(RHEUMATOID FACTOR)

(RF)

 OBSTETRIC PANEL (OB PANEL)

(OB) 80055  EB EA IgG

(EBEA)

86663  RPR (SYPHILLIS VDRL RPR QL) **(RPR)

86592

 RUBEOLA (MEASLES AB SCREEN)

 RENAL FUNCTION PANEL

(RFPAN)

80069  FERRITIN

(FERRI)

82728

86765

(MEAS)

LABORATORY

 FOLATE (FOLIC ACID)

(FA)

82746  RUBELLA SEROLOGY

(RUB) 86762

 ALBUMIN

(ALB) 82040  FSH

(FSH)

83001  SEDIMENTATION RATE

(ESRA) 85652

 ALKALINE PHOSPHATASE

(ALKP)

84075   G GT

(GGT) 82977  SODIUM

(NA)

84295

 GLUCOSE

 ALT

(ALT) 84460

82947  T3 UPTAKE

(T3U)

84479

(GLU)

 HBSAG (HEPATITIS Bs ANTIGEN)**

 AMYLASE

(AMYL) 82150

87340  TSH

(TSH)

84443

(HBSAG)

(EIA QL HBSAG)

 T4 (THYROXINE)

(T4)

 ANA (ANTINUCLEARANTIBODY)** (ANA) 86038   H BSAB (HEPATITIS Bs ANTIBODY) (HBSAB) 86706

84436

 APTT

(APTT)

85730  HCV ULTRASENSITIVE VIRAL LOAD (HCVUS)

87521  T4 – FREE (FREE-THYROXINE)

(FT4)

84439

 AST

(AST) 84450  HCV VIRAL LOAD

(HCVVL) 87522  THEOPHYLLINE

(THEO)

80198

 BUN

(BUN) 84520  HEPATITIS C ANTIBODY **

(HCV)

86803  TOTAL BILIRUBIN

(TBIL) 82247

 CALCIUM

(CA) 82310  HIV VIRAL LOAD

(VIRLD)

87536  TOTAL PROTEIN

(TP) 84155

 CBC

(CBC) 85025  HIV SEROLOGY* **

(HIVS)

86703  TRANSFERRIN

(TRFS) 84466

 CBC NO DIFF

(CBCN) 85027  HCG, QUANTITATIVE

(HCGQ) 84702  TRIGLYCERIDES

(TRIG)

84478

START DATE/TIME: ________________

 CARBAMAZEPINE (TEGRETOL) (CBAM) 80156  HDL

(HDLL)

83718

STOP DATE/TIME:

 CREATININE CLEARANCE, 24 HOUR

 CEA

(CEAM) 82378  HGB A1C

(A1C) 83036

82575

Ht:

Wt:

(CCL)

 CHLORIDE

(CL) 82435  H. PYLORI AB IGG SEROLOGY

(HPYL) 86677  URINE, TOTAL PROTEIN, 24 HOUR (TPUR)

84155

 CHOLESTEROL

(CHOL) 82465  IRON

(IRON)

83540  URINALYSIS

(UA)

81001

 CO2

(C02) 82374   I RON STUDY

(Fe)

83550  URINE PROTEIN- RANDOM

(RPUR)

84156

 CORTISOL

(CORT)

82533   L IPASE

(LIP)

83690  VITAMIN B12

(VB12)

82607

 C-REACTIVE PROTEIN

(CRP)

86140  LITHIUM

(LITH)

80178 TRANSFUSION

86900

 CREATININE

(CREA) 82565  MAGNESIUM

(MG)

83735  BLOOD TYPE

(ABO AND BBRH)

86901

 C-REACTIVE PROTEIN – CARDIAC

86141   M ONO SCREEN

(MONO)

86308  ANTIBODY SCREEN**

(ABSC) 86255

(HSCRP)

 DIGOXIN (LANOXIN)

(DGN)

80162  PHENOBARBITAL

(PHNO) 80184  DIRECT COOMBS **

(DC)

86880

 DILANTIN (PHENYTOIN)

(PTN)

80185  PHOSPHORUS

(PHOS) 84100  OTHER:

 DIRECT BILRUBIN

(DBIL)

82248  POTASSIUM

(K)

84123  OTHER:

*HIV Consent form must be signed and accompany the specimen or fax to 388-9637. ** These tests may be reflexed for titer or further confirmation if positive. Medicare will only pay for tests that

meet the Medicare coverage criteria and are reasonable and necessary to treat or diagnose an individual patient, routine screening tests generally are not covered

ICD-9/Diagnosis Code(s):________________________________

Healthcare Provider Name:______________________________________________________

_____________________________________________________

Healthcare Provider Signature:____________________________________________________

Send Results To:

LAB OUTPATIENT ORDER FORM

17-6163

10-08