USE BALL POINT PEN ONLY Fax to Practitioners Office #

q ROUTINE REQUIRED

q STAT CALL REPORT # _________________

q STAT CALL REPORT-- PATIENT TO WAIT # ____________________

Pt. Name : Last First Middle Pt. D.O.B. Practitioner Signature Date

Time

Precert / Authorization # Print Name of Practitioner

Expires on:

P CPT(s) P CPT(s) P Test CPT(s)

85025 82150 Pregnancy Test, 84702

85027 ANA (Anti-nuclear AB) 86038 Serum HCG, Quant

Cell Count with Diff: 82247 Protein Electrophoresis, 84165

Serum (SPEP)

PSA (Prostate Specific Antigen) 84153

85045 Brain Natriuretic Peptide85651 84520 RA (Rheumatoid Factor) 86431

82378 RPR (Syphilis Serology) 86592

Partial Thrombo Time (PTT) 85730 82550 Rubella Screen 86762

Prothrombin Time (PT with INR) 85610 82553 T3, Free (Free T3) 84481

D-Dimer, Quantitative 85379 82565 T4 ,Free (Free T4) 84439

Creatinine Clearance 82575 Total Protein, 24 Hr Urine 84156

81001 CRP (C -Reactive Protein) 86140 Troponin I 84484

TSH (Thyroid Stimulating Hormone) 84443

Acid Fast Culture & Smear 87116 (Highly Sensitive/Cardiac) Uric Acid ,Serum 84550

80162 Valproic Acid (Depakene) 80164

Blood Cult & Sensitivity 87040 80185 Varicella AB, IgG 86787

Clostridium Difficile Toxin 87324 82728 Vitamin B12 & Folate

87102 82731

82947 Vitamin D,25 Hydroxy 82306

87205 82950

82950 Arthritis 86255

Influenza A&B Screen (Rapid) 87804 82951 Basic Metabolic (BMP) 80048

Ova & Parasites (O & P) 87177 Glucose Tolerance Test 82951 Comprehensive Metabolic (CMP) 80053

87070 Circle Hrs: 2 3 4 5 6 Liver (Hepatic Function) 80076

Pertussis smear, DFA 87265 Hemoglobin A1C Glycohemo 83086 Hepatitis,Acute 80074

87798 Hep B Surface Antign (HBSAG) 87340 Lipid 80061

Hepatitis B Surface Antibody 86706 Renal Function 80069

Rotavirus Screen,Stool (Rapid) 87425 Hepatitis C Antibody 86803

RSV Screen (Rapid) 87807 HIV Profile / Test 86703 Thyroid Panel 84481/

Sputum Culture and Sens 87070 Iron & TIBC (FE & TIBC) 83540/87045 with % Sat 8355083630 Lipase 83690 Other tests or procedures

Strep Screen (Rapid) 87430 Lithium 80178

87070 Monospot 86308

Urine Culture & Sens 87086 Occult Blood, Stool 82272

Phenobarbital 80184

Cult & Sensitivity, Miscellaneous 87070 Potassium (K+),Serum 84132

Must specify source: Pregnancy Test, urine 84703

~~NON-SCHEDULED~~

Pt. SEX:

M or F

Laboratory Outpatient Hours: Monday thru Friday

7:30 am- 5:00 pm

CHEMISTRY (CON'T)HEMATOLOGY

Pt. Phone #:

LABORATORY ORDER FORM

FAX: 336-633-7787

Test

CHEMISTRY

Pertussis culture

PANELS

PTH Intact with Calcium

Retic Count

Urinalysis (UA)

Glucose

83970 /

82310

BNP (NT-proBNP)

Amylase

Fetal Fibronectin

Specify source:

q Cath q Clean Catch

Throat Culture

Stool for WBC's

Stool Culture

BUN

Gram Stain

SED Rate (ESR)

89050/

89051 82247/

82248

82746/

82607

86141

83880

Dilantin

Digoxin (Lanoxin)

Creatinine

CK MB

85014/

85018

Bilirubin, Total & Direct

Bilirubin, Total only

84439/

84443

CBC with Diff

CBC (no Diff)

Specify Source:

HGB and HCT (H&H)

BO

TH

Re

qu

ire

d

Test

(TSH,Free T3, Free T4 )

COAG STUDIES

URINALYSIS

MICROBIOLOGY

Ferritin

CK-total

CEA

Pertussis by Polymerase Chain

Reaction (PCR)

hs-CRP

Glucose-Post Glucose-PG 2hr.

Glucose-Post Glucose-OB 3hr.

Specify source:

Fungus Culture

Specify source:

Glucose-Post Glucose-PG 1hr.

ICD 10 Code :

Reason for Exam:

Revised 1/2017 Outpatient Lab Form

*164000020* 169900002 RH_OP_LAB