Clinical Laboratory Order

Clinical Laboratory Order
Name (Last)
Birth Date
(First)
(M.I.)
Maiden or Previous Name
Sex
M
Patient Address
F
LAB USE ONLY - FOR IMAGING LABEL
All orders require a signature from the provider to process
Provider Signature Phone
Print Provider Name
Copy of Report to
Primary Insurance Company
Phone
Date of original order
Attach copy of insurance card(s)
Responsible Party
Primary Diagnosis & ICD-9 Code(s) or Symptoms
Relationship to Patient
Patient is: Subscriber
Spouse
Other/Dependent
Subscriber is: Retired
Employed
Only tests medically necessary for diagnosis or treatment may be billed to Medicare or Medicaid
Tube Types: B = Blue, BB = Blood Bank 7ml Lavender, (FT) = Full Tube Required, G = Grey, L = Lavender, SST = Serum Separator, 24 UB = 24 Hour Urine
Priority
Routine
Specimen Collection
Stat
Non-Fasting
Standing Order Exp. Date
Frequency
PANELS*
Call Results to #
8-hr Fasting
Fax Results to #
12-hr Fasting
Date
Time
Initials
CARDIAC RISK TESTS
CRP - Cardiac/High Sensitivity
CRH 86141SST
Cholesterol
CHO82465SST
HDL - Cholesterol
HDL 83718SST
* See Separate listing for individual tests
Homocysteine (Blood)
HOM 83090SST
ACUTE HEPATITIS PANEL
BNP 83880L
Hepatitis A Ab (IgM), Hepatitis B Core Ab (IgM)
AHP 80074SST BNP - Brain Natriuretic Peptide
Hepatitis B Surface Ag, Hepatitis C Ab
Lipoprotein (a)
LPA 82172SST
LIPID PANEL
TRG 84478SST
LPD 80061SST Triglyceride
Chol, Trig, HDL, LDL (calc.), Chol/HDL ratio
INDIVIDUAL TESTS
RENAL FUNCTION PANEL
ALB 82040SST
Ab, Anion Gap, Bicarb, BUN, Ca, Cl, Cre, RFP 80069SST Albumin
Glu, K, Na, Phos
AST (SGOT)
AST 84450SST
ELECTROLYTES
ALT 84460SST
LYT 80051SST ALT (SGPT)
Anion Gap, Bicarb, Cl, K, Na
Alkaline Phosphatase
ALP 84075SST
BASIC METABOLIC PANEL
BMP 80048SST Amylase
Anion Gap, Bicarb, BUN, Ca, Cl, Cre, Glu, K, Na
AMY82150SST
COMPREHENSIVE METABOLIC PANEL
BhCG, Serum Quantitative
HCG 84702SST
Alb, ALP, Anion Gap, Bicarb,Bill (total), BUN
CMP 80053SST
Bicabonate
CO2 82374SST
Ca, Cl, Cre, Glu, K, Na, SGOT, SGPT, T, Protein
82247
Bilirubin (Total, Direct, Indirect)
TDB
82248SST
LIVER FUNCTION PANEL
Alb, ALP, Bill (Total & Direct), SGOT, SGPT,
LIV 80076SST BUN
BUN84520SST
T. Protein
Calcium
CA 82310SST
OBSTETRIC PANEL
CBC, TYP
CL 82435SST
Antibody Screen, RH, Type, CBC, Rubella, RPR
ABS, RPR 80055 SST, L Chloride
Hepatitis B Surface AG
HBS, RBS
BB
Creatinine
CRE 82565SST
GLUCOSE TESTS
Digoxin
DIG 80162SST
Fasting Glucose
GLU 82947 G Estradiol
EST 82670SST
1 hr. post Cola (50g), nonfasting
GLN 82950G Ferritin
FER 82728SST
1 hr. post Cola (50g), includes fasting glucose GL 1 82950 G Folate, Serum
FOL 82746SST
2 hr. post Cola (75g), includes fasting glucose GL 2 82950 G Folate, RBC
RFO 82747L
2 hr. post meal glucose
GLP 82950G Free T3
FT3 84481SST
Insulin, Fasting
IN
83525SST Free T4
FT4 84439SST
Insulin 2-hr
Post Cola
Post Meal 12H/12P 83525SST Follicle Stimulating Hormone
FSH 83001SST
COAGULATION TESTS
GGTP
GGT 82977SST
A1C 83036L
PT with INR
PT
85610B(FT) Hemoglobin A1C
83020L
APTT
PTT 85730B(FT) Hemoglobin Electrophoresis†HBE
FE 83540SST
D-Dimer, quantitative
DD
85378B(FT) Iron
FE+IBC 83550
Fibrinogen
FIB 85384B(FT) Iron + Binding Capacity
83540 SST
Lutenizing Hormone
LH
83002SST
BLOOD BANK
83970
86900
PTH
Parathyroid Hormone Intact + Calcium†
82310 SST
ABO & RH Blood Type
TYP
86901BB
K 84132SST
Antibody Screen
ABS 86850BB Potassium
TP
84155SST
Direct Coombs
DAT 86880BB Protein, Total
PSD 84153SST
CORD (TYP + DAT)
CRD
BB PSA, Diagnostic
PSS G0103SST
Antibody Titer; Anti-
TI
86886BB PSA, Screening
SPG 84703SST
Crossmatch Blood Products #
BB* Serum Pregnancy
Sodium
NA 84295SST
Type of Product:
Special Product Requirements:
TSH
TSH 84443SST
Date to be given:
TSH, Reflex Free T4
TSH 84443SST
* Pretransfusions Specimens require a fenwal typenex wristband
Vitamin B 12
B12 82607SST
HEMATOLOGY
Vitamin D, 25-Hydroxy
V25 82306SST
CBC with Diff
CBC 85025L
INFECTIOUS DISEASE SEROLOGY
86644
Hemogram with platelet (WBC, RBC, HGB,
CMV Antibody Fraction (IgG & IgM)
CMF
86645 SST
HEM 85027
86664
HCT, PLT, MCV, MICH, MCHC, RDW)
L EBV (Panel IgG & IgG) + EBNA
EBV
86665 SST
86900
Hemoglobin & Hematocrit
HH
85014L
Helicobacter pylori Antibody (IgG)
HPY 86677SST
SIC 85660L Hepatitis A Antibody (IgM)
Sickle Screen Do Hb Elect. if pos.
HAV 86709SST
Sedimentation Rate (ESR)
ESR 85651L(FT) Hepatitis B Core Antibody (IgM)
HBM 86705SST
Reticulocyte CountRET
85044L Hepatitis B Surface Antibody
HBB 86706SST
87340
ARTHRITIS TESTS
Hepatitis B Surface Antigen w/Confirm HBS
87341 SST
86803
AntiNuclear Antibody
ANA 86038SST Hepatitis C Antibody with RIBA Confirm HEC
86804 SST
86694
C-Reactive Protein (CRP)
CRP 86140SST Herpes IGG/IGM w/reflex
HSR
86694 SST
RA (Rheumatoid Factor)
RF
86431SST HIV Antibody w/confirm CONSENT OBTAINEDHIV 86703
86689 SST
Uric Acid
URC 84550SST Lyme Antibodies with Western Blot ConfirmLYM 86618
86617 SST
Additional Testing/Comments:
702-1-10 revised 5/14
Mono (infectious) EBV if negative
MON 86308SST
Mumps Antibody Screen (IgG)
MUM 86735SST
Mycoplasma Antibody (IgG)
MYG 86738SST
Mycoplasma Antibody (IgM)
MYM 86738SST
RPR (Syphyllis Serology)
RPR 86592SST
Rubella Screen
RBS 86762SST
Rubeola Antibody (Measles) Screen (IgG)MEA 86765 SST
Toxoplasma Antibody (IgG & IgM)
TOX 86777
86778SST
Varicella Zoster Antibody (IgG)
VAR 86787SST
URINE TESTS
(circle source)
CCMS
Straight Cath
Ind. Cath
Urinalysis with reflex microscopy
UA 81003
Urinalysis Dipstick only
UAD 81003
Urinalysis with microscopy
UAM 81001
Urine Culture if >5 WBC’s on UA
UAF 87086
Urine Culture
UC 87086
Micro Albumin, random
MSU 82043
24UB
Creatinine Clearance + Blood Creat
CCL 82575
82565
SST
Urea Nitrogen, 24 hour
UUN 84540 24 UB
Protein, 24 hour
UP 84155 24 UB
Urine Pregnancy
UPG 81025
FECES (STOOL) SPECIMENS
87015
Giardia/Cryptosporidium
CGS 87272
Ova and Parasite studies 1 or 3 (please indicate) OP 87177
Stool culture for enteric pathogens: Salmonella87045
SC 87046
Shigella Campylobacter, Enterohemorrhagic E. coli
C. difficile toxin assay
CDT 87324
Smear for WBC’s
SMW 87205
Rotavirus Screen
ROT 87425
Occult Blood
OCB 82270
H. pylori Antigen
HAG 87338
MICROBIOLOGY & VIROLOGY
Cultures include ID & Susceptibility studies if indicated
Microbiology phone 226.7240 Virology phone 226.5660
Specimen Source (required):
87116
AFC 87206
AFF
Anaerobe CultureAC
87075
Bacterial Culture
87140
Chlamydia CultureCHL
87110
Chlamydia & Neisseria Gonorrhoeae RNA Test CGW/CGU 87590
87490
CHS/CHU 87490
Chlamydia RNA Test
CGS/CGU 87590 Neisseria Gonorrhoeae RNA Test
Enterovirus Culture
ENT 87254
Flu Screen (includes rapid test)
FLU 87804
Fungal Culture
FNC
Gram Stain
PGS 87205
Group A Strep Screen (throat)
SS 87081
Group B Strep Screen (genital)
GSS 87081
Herpes Simplex Culture
HSC 87252
Herpes Simplex Culture w/typing (I & II) HST 87252
HPV (Human Papilloma Virus) DNA Test HPV 87621
KOH Prep (nail, skin scraping)
KOH 87220
MRSA Screen
MRC 87081
Respiratory Viral Culture
RSP
RSV Screen (includes rapid test)
RSV
Vanicella (Herpes) Zoster Culture
VZV 87254
AFB Culture/Smear
DNA Probes for Trich, Cand. Sp. & Gard. (Affirm)
† This test includes a consultation and interpretation by a pathologist.
Borgess Medical Center – Stryker Center
1521 Gull Road, Kalamazoo
(269) 226.5917
Outpatient Hours:
Monday-Friday: 7 a.m.-6 p.m.
Saturday: 8 a.m.-Noon
43
131
Exit 41
43
N
N
Milham Rd.
94
N
Borgess –
Westside
W. Main St. (M-43)
N
Portage Rd.
Sprinkle Rd.
9th St.
Dr.
as
Oakland Dr.
Park St.
Westnedge Ave.
e St.
Portag
Oakland Dr.
Sprinkle Rd.
131
Bus
ines
s 13
1
Kalamazoo
Dr.
Stadium
94
Westnedge Ave.
.
l Rd
Gul
e St.
Portag
94
Westnedge Ave.
Sha
ffer
Currier Dr.
11th St.
12th St.
Moorsbridge Rd.
Oakland Dr.
Borgess at
Woodbridge Hills – South
Main St.
Naomi St.
BorgessLee Memorial
Hospital
W. Division
W.
Ma
in
51
Douglas Ave.
Riverview Dr.
62
W. Centre Ave.
Romence Rd.
Portage
Milham Rd.
Oakland Dr.
Tex
131
Borgess at
Woodbridge
Hills – North
N
Park St.
Borgess
Medical
Commons –
Currier Dr.
N
E. Centre Ave.
94
62
51
W.
Hig
hS
t.
Paul St.
Lowe St.
Dowagiac
Riverview Dr.
Romence Rd.
Portage
W. Centre Ave.
E. Bridge St. (M-89)
Plainwell
66
Beckley Rd. / B Dr. N
Douglas Ave.
E. Main St.
96
Exit 80
g
kin
Par
131
66
Borgess
Health Park
Battle
Creek
BorgessPipp
Hospital
Alle
g
a
n
St.
(M-8
9)
Otsego
N
94
B Dr. S
Lovers Ln.
-94
BL I
kin
Par
)
-43
. (M
l Rd
Gul
g
King Hwy
St.
ffer
Sha
Borgess
Medical
Center
Paterson St.
94
S.
Flo
r
i
da
Rd
.
Delton
E. Orchard St.
al
dic ties
Me ecial g
Sp ildin
Bu
43
ad
l Ro
Gul
Kalamazoo
Bus
ines
s 13
1
W. Main St.
Dr.
Stadium
Riverview
N
r
yke
Str nter
Ce
Delton Rd.
ss
rge l
Bo dica
Me nter
Ce
g
kin
Par ucture
Str
N
Douglas Ave.
Medical Specialties Building
1535 Gull Road, Suite 030, Kalamazoo
(269) 226.8317
Monday-Friday: 8 a.m.-5 p.m.
Borgess Medical Commons –
Currier Drive
7895 Currier Drive, Portage
(269) 321.7100
Monday-Friday: 8 a.m.-4 p.m.
Closed for lunch: 1 p.m.-1:30 p.m.
Borgess – Westside
6565 West Main Street, Kalamazoo
(269) 372.7459
Monday-Friday: 8 a.m.-5 p.m.
Borgess-Pipp Hospital
411 Naomi Street, Plainwell
(269) 685.0746
Monday-Friday: 7 a.m.-6 p.m.
Saturday: 7 a.m.-Noon
Borgess at Woodbridge Hills – North
7901 Angling Road, Portage
(269) 324.8400
Monday-Friday: 7 a.m.-8 p.m.
Saturday: 8 a.m.-Noon
Borgess Medical Commons – Delton
(in the Delton Medical Center Building)
11320 S. M-43, Suite 2, Delton
(269) 623.2334
Monday-Friday: 7:30 a.m. to 4:30 p.m.
Crooked Lake
Sprague Rd.
Borgess
Medical 43
Commons –
Delton
W. Osborne Rd.
Fro
nt
Borgess Health Park
3035 Capital Avenue SW, Battle Creek
(269) 565.9100
Monday-Friday: 7 a.m.-6 p.m.
Borgess-Lee Memorial Hospital
420 West High Street, Dowagiac
(269) 782.8681
Monday-Friday: 7 a.m.-5 p.m.
Saturday: 8 a.m.-Noon
43
Rd.
ling
Ang
Shaver
Rd.
Pleasant Lake Rd.
St.
Capital Ave. SW
Cass

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