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OB/GYN Laboratory Services

(719) 365-5260

memorial central clia # 06d0663026

memorial north clia # 06d1065861

patieNt iNfOrmatiON

patient Name: (Last) ___________________________ (first) ____________________________ (mi) ______ Sex:

f D.O.B. ______ / ______ / ______

cOLLectiON Date: ______ / ______ / ______ and time: ___________________ SOciaL SecuritY NumBer: ____________________________________

BiLLiNG iNfOrmatiON:

insurance: attach copy of patient's insurance and demographic information

medicare: complete aBN on reverse side and attach copy of insurance/demographic information

Self pay patients: attach copy of patient's demographic information

Doctor / clinic

Ordering provider:

Diagnosis or icD-9 Diagnosis code:

priOritY:

Stat results are called and faxed

rOutiNe results are faxed

GeNeraL LaBOratOrY teStiNG

preNataL ScreeNiNG

___ 17 OH prOgesterOne

___ fOlate (rbc)

___ pOtassium serum

requireS GeNzYme requiSitiON

83498

82747

84132

___ albumin

___ fOlate (serum)

___ pregnancy screen

___ integrated scr 1st trimester

82040

82746

84703

___ alk. pHOs

___ fsH

___ pregnancy (Hcg) quant

84075

83001

84702

82105, 82677, 84702, 86336, 84163

___ alt (sgpt)

___ ggt

___ prOgesterOne

___ integrated scr 2nd trimester

84460

82977

84144

___ amylase

___ glucOse serum

___ prOlactin

82150

82947

84146

82105, 82677, 84702, 86336, 84163

___ ana

___

___ prOtein tOtal, serum

___ sequential prenatal scr 1

glucOse 1 Hr tolerance

86039

82950

84155

___ ast (sgOt)

___

___ pt/inr

glucOse 3 Hr tolerance

84450

82951, 82952

85610

84163, 84702

___ basic metabOlic

___ HemOglObin a1c

___ ptt

___ sequential prenatal scr 2

80048

83036

85730

___ Hgb electrOpHOresis

___ rpr

(na, k, cl, cO2, creat, bun, gluc)

83020

86592

82105, 84702, 82677, 86336

___ bilirubin, tOtal

___ Heparin assay: lmwp

___ rubella igg

fiLL Out iNfOrmatiON BeLOw

82247

85520

86762

___ bilirubin, direct

___

___ rubella igm

___ afp single marker

Heparin assay unfract: Hep Xa

82248

85520

86762

82105

___ btnp (bnp)

___ Heparin induced plt ab pf4

___ rubeOla (measles) igg

___ quad screen

83880

86022

86765

___ Hepatitis viral prOfile

___ rubeOla (measles) igm

(b type natriuretic peptide)

80074

86765

82105, 82677, 84702, 86336

___ bun

___ sedimentatiOn rate

race: black: Other:

84520

(Hbsag, Hbcab igm, Haab igm, Hcvab)

85652

___ calcium

___ Hiv antibOdy

___ sOdium serum

iddm:

yes

82310

86703

84295

___ cbc w/ diff

___

___ t4 (tHyrOXine)

weight: _____________ lbs.

85025

HypercOagulability Order grOup

84436

___ cbc w/o diff

___ t4 free

# of fetuses: _____________

85027

84439

call lab fOr cpt cOdes. circle requested tests:

___ t3

edd: _____________

(wbc, rbc, Hct, Hgb, mcv, mcH, plt)

84480

(pt, ptt, lupus anticOag., antitHrOmbin iii

___ cHlamydia 3 species igg/igm

___ t3 free

edd determined by:

84481

assay, c & s functiOnal activity, activated

___ tsH

(circle one)

86631 x3, 86632 x3

84443

prOtein c resistance, prOtHrOmbin ii 20210,

___

___ tsH refleX to free t4

cOmpreHensive metabOlic

u/s

lmp

80053

84443

HOmOcysteine, and cardiOlipin ab)

___ irOn level

___

uriNe

testOs. free & tOtal

(alb, alk, pHOs, ast, alt, bili-t, bun, ca,

83540

84402, 84403

___ irOn Order set

___ testOs. tOtal

___

urinalysis

cl, cO2, creat, gluc, k, na, t. prOtein)

83540, 84466

84403

w/cult if ind. 81003, 87086

___ creatinine serum

___ transferrin

___ urinalysis

82565

(irOn, transferrin, % sat)

84466

81003

___ cystic fibrOsis screen

___ lH

___ varicella igg

___ culture, urine

83002

86787

87086

___ lipid prOfile, refleXive

___ varicella igm

___ prOt/creat ratiO

83891, 83900, 83892x 39, 83896x 39, 83903

80061

86787

84156, 82570

___ prOtein, 24 Hr

micrOBiOLOGY

please circle required info:

(cHOl, trig, Hdl cHOl, ldl calc Or

84156

___ viral culture

___ creat, clear. 24 Hr

screen or diagnOstic

measured if trig abn)

87252

82575

___ liver functiOn prOfile

(w/serum creat.) (Ht: ________ wt: _________ )

race: caus, african, asian, Hispanic, Other/unk

80076

sOurce:

___ Herpes viral cult.

___ tOXicOlOgy scr

clinical symptoms: yes or nO

87252

80101x5

(ast, alt, bili-t & d, alk pHOs, alb, t. prOtein)

___ magnesium

family HX: yes or nO or unk

83735

sOurce:

(amphet. cocaine, Opiates, tHc)

___ mOnO screen

___ genital culture

BLOODBaNk teStiNG

if yes describe family relationship:

86308

87070

___ dHea-s

___ mumps igg

___ abO-rH

82627

86735

sOurce:

86900, 86901

___ electrOlytes

___ mumps igm

___ gbs culture

___ antenatal rHOgam

80051

86735

87081

86900, 86901

___ prenatal prOfile

___ antibOdy screen

(na, k, cl, cO2)

80055

sOurce:

86850

___ estradiOl

___ gbs culture pcn allergy

___ type & screen

82670

(abO-rH, antibOdy scrn, Hbsag,

86850, 86900, 86901

___

miSceLLaNeOuS teStiNG

factOr v leiden

call lab for cpt code

HemOgram, rpr, rubella)

sOurce:

___ fetal fibrOnectin

___

___ cHlamydia dna

pfa 100 platelet func. test

82731

85576

87491

___ fetal mat. HemOrrHage

___ gOnOrrHea dna

85460

(call tHe lab fOr instructiOns)

87591

___ ferritin

___ pHOspHOrus

82728

84100

1252556 (12/2011)

Ob Gyn Laboratory Services - Mayo Medical Laboratories, Form Cms-R-131 - Advance Beneficiary Notice Of Noncoverage (Abn)

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