ANMC Lab Field Requisition - Alaska Native Medical Center
ANMC LABORATORY FIELD REQUISITION Alaska Native Medical Center Laboratory City/Village FULL NAME (NO ABBREVIATIONS) 4315 Diplomacy Drive Anchorage, AK 99508 Phone: (907) 729-1200, Fax: (907)729-1227 All Information in yellow/red fields is required. Use full names (NO ABBREVIATIONS). Field Requisition and Specimen Requirements Into Available at: http://anmc.org/services/laboratory Diagnosis/Signs/Symptoms in ICD-9 or IDC-10 Format (Highest Specificity) Patient's Name (Last) Patient's Name (First) Clinic's FULL NAME (NO ABBREVIATIONS) Clinic's Phone # Clinic's Fax # Collection Date Collection Time Bill To: __ Client/Clinic __ Medicare ( __ Primary __ Secondary) __ Medicaid __ Other Insurance Sex Date of Birth Patient's Relationship to Insured Person: __ Self Provider's Name (Last) MR # Provider's Name (First) __ Spouse __ Child __ Other Insured Person's Full Name (If Not Pt) (Last, First) Note: Only order those tests which are medically necessary for the diagnosis and treatment of the patient. Medicare does not pay for tests for which documentation does not support that the tests were reasonable and necessary. Medicare generally does not cover routine screening tests, even if you consiter the tests appropriate. Insurance Company Name Insured's SS # Subscriber/Member # Carrier Code Plan Name or # Group # Physician's Provider # Workers's Comp (Y/N) Employer's Name Employer's # Provider's Signature: ______________________________________________________________________________ COMMON TEST PANELS Acute Hepatitis Panel (HAV IgM, HBV Core IgM, HBV Surface Ag, HCV Ab) Basic Metabolic Panel (Na, K, Cl, Glu, CO2, BUN, Creat, Ca, GFR) Chronic Hepatitis Screen (HAV Ab, HBV Core Ab, HBV Surface Ab, HCV Ab) Comprehensive Metabolic Panel (Na, K, Cl, Glu, CO2, BUN, Creat, Ca, TP, Alb, TBili, Alk Phos, ALT, AST, GFR) Electrolyte Panel (Na, K, Cl, CO2) Hepatic Function Panel (Alb, TBili, DBili, Alk Phos, TP, ALT, AST) Lipid Panel (Fasting Specimen) (TChol, Trig, HDL, LDL, Chol:HDL Ratio) Renal Function Panel (Na, K, Cl, Alb, Ca, CO2, Creat, Glu, PO4, BUN, GFR) HEMATOLOGY TESTS Hemoglobin and Hematocrit CBC with Differential CBC without Differential Manual Differential Reticulocyte count Erythrocyte Sedimentation Rate (ESR) SST SST SST SST SST SST SST SST LAV LAV and SMEAR LAV SMEAR LAV LAV ALPHABETICAL TESTS ABO Group & Rh Acetaminophen AFP Albumin Alkaline Phosphatase ALT Amylase Pink or LAV Antibody Screen w/ Reflex Antibody ID * Pink or LAV Antibody Titer AST Bilirubin, Direct Bilirubin, Total Calcium Cholesterol, Total CK, Total Pink or LAV SST SST SST SST SST SST SST SST SST SST SST SST Legend: * = Has potential reflexive testing. Note: In general, all specimens should be sent with a gel cold-pack. Refer to chart on ANMC webite for specimen type, stability, and transport requirements: http://anmc.org/services/laboratory/specimen requirements Updated 3/31/15 ALPHABETICAL TESTS Creatinine Direct Antiglobulin Test (DAT) Digoxin Ethanol Ferritin Folate Gentamicin GGT Glucose HCG (Serum), Quant HCG (Urine), Qual Hemoglobin A1C Hep A Antibody, Total IgG/IgM Hep A Antibody, IgM Hep B CORE Antibody * Hep B Core IgM Antibody Hep B Surface Antibody Hep B Surface Antigen * Hep B CARRIER PANEL w/ AFP Hep C Antibody Hep C CARRIER PANEL w/ AFP HIV Screen * Iron Panel (Iron, TIBC, UIBC, % Sat) Iron, Total LDH Magnesium Phenobarbital Phenytoin (Dilantin) Phosphorous PT with INR PTT, Activated Potassium (K) PSA PSA w/ Reflex Free PSA * PTH, Intact RPR Rubella Antibodies, IgG Salicylate Sodium SST Pink or LAV SST SST SST SST SER SST SST SST URINE LAV SST SST SST SST SST SST SST SST SST ALPHABETICAL TESTS T-3, Free T-4, Free T-4, Total Triglyceride TSH TSH w/ Reflex FT4 * Urinalysis Dipstick Only Urinalysis w/ Reflex Micro & Culture * Urinalysis w/ Microscopic Exam Valproic Acid Vancomycin Vitamin B12 Vitamin D 25 OH, Total MICROBIOLOGY TESTS SST SST SST SST SST SST BD Tube BD Tubes BD Tube SST SST SST SST Source of Specimen (REQUIRED): SST SST SST Aerobic Bacterial Culture (Source: ___________________ ) SST Anaerobic Bacterial Culture (Source: _________________ ) Swab SST Chlamydia/GC (APTIMA) (Source: __________________ ) APTIMA SER Clostridium Difficile (DNA Amplification) Stool SER Gram Stain (Source: ___________________ ) Swab SST SST Influenza A & B (Rapid Antigen) Hep B Quant Viral Load (PCR) Hep C Quant Viral Load (PCR) Parasite Antigen Panel Rotavirus (Rapid Antigen) RSV (Rapid Antigen) Sputum, Upper Respiratory Culture Stool Culture Throat Culture, Beta Strep Group A SST Trichomonas (APTIMA) (Source: ___________________ ) BLUE BLUE SST SST SST SST SST SST Prenatal Triple Test/Maternal Serum Evaluation Gestational Wks: ________ Maternal Weight: ________ Race: _______________ Insulin Dependent: _____ Previous Results/History: ________________________ Swab NP Swab SST SST Alpha Tec Stool NP Swab Sputum Alpha Tec Swab APTIMA Urine Culture __ Clean Catch __ Cath BD Tube ADDITIONAL TESTS / NOTES / 24 Hour Urine Volume
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