Lyme Disease PCR
| 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. Lyme Disease PCR | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
LYMPC
Test Workstation :
MAYO
Specimen Type:
Whole Blood
Tube Type:
Purple top (EDTA) tube
Collection Volume:
1.0 mL (minimum 0.3 mL)
Cause for Rejection:
Anticoagulants other than EDTA
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Real-Time Polymerase Chain Reaction (PCR)/DNA Probe Hybridization
Lab/Phone:
330-543-8418
TAT:
1-4 days
CPT Code:
87476, 87798x2
Panel Includes:
Borrelia burgdorferi PCR
Borrelia mayonii PCR
Borrelia garinii PCR
Borrelia afzelli PCR
Synonyms:
Borrelia burgdorferi PCR
Borrelia mayonii PCR
Borrelia garinii PCR
Borrelia afzelli PCR
