Bilirubin, Total
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Bilirubin, Total | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
TBILI
Test Workstation :
MACH3
Specimen Type:
Blood
Tube Type:
Green top (lithium heparin) tube
Collection Volume:
500 uL microtainer; 1.5 mL macrotainer
Minimum Volume:
500 uL microtainer; 1.5 mL macrotainer
Preferred Volume:
500 uL microtainer; 1.5 mL macrotainer
Storage:
Shipping: Refrigerated (protect from light); Storage Room Temp: 1 day; Refrig: 7 days.
Availability:
24 Hours/day, 7 days/week
Methodology:
Roche-Diazo Method
Special Instructions:
Protect specimen from light exposure. Ask that the bilirubin lights in the NICU be turned off while collecting.
Lab/Phone:
330-746-9623
TAT:
1 hour
Additional Info:
Reference range is age dependent; available on patient report.
CPT Code:
82247
