Cytomegalovirus (CMV), Reflex to Quantitative PCR

Molecular Diagnostics - : DNA

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. Cytomegalovirus (CMV), Reflex to Quantitative PCR
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

LAB3993

Specimen Type:

Blood (plasma)

Collection Volume:

Blood (plasma): 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)

Cause for Rejection:

Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Sample Exceeds Holding Time

Storage:

Refrigerated

Availability:

Mon-Fri (7:30-16:00)

Methodology:

Real-Time Polymerase Chain Reaction

Special Instructions:

Upon arrival in laboratory, promptly centrifuge blood specimen tube and send 1.0 mL of the plasma to the Molecular laboratory. Refrigerate.

Lab/Phone:

330-543-8722

TAT:

1-3 days

CPT Code:

87496 if Qualitative result is reported
87497 if Quantitative result is reported

Synonyms:

CMV DNA
CMVR

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Cytomegalovirus (CMV), Reflex to Quantitative PCR

Molecular Diagnostics - : DNA

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