Diazepam and Nordiazepam
| 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. Diazepam and Nordiazepam | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
DIAZA
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
1.5 mL (1.0 minimum)
Cause for Rejection:
Use of serum gel tube.
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Lab/Phone:
330-543-8418
TAT:
3-7 days
Additional Info:
Therapeutic concentrations: 200-2,500 ng/mL
CPT Code:
80346, G0480 (if appropriate)
Panel Includes:
Diazepam
Nordiazepam
Diazepam and Nordiazepam
