Lyme Disease, Western Blot (Mayo)
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
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| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Lyme Disease, Western Blot (Mayo) | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
LYWB
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top tube - serum
Collection Volume:
2.0 mL
Minimum Volume:
1.5 mL
Cause for Rejection:
Specimen rejected; Grossly hemolyzed, grossly lipemic, grossly icteric
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Immunoblot
Lab/Phone:
330-543-8148
TAT:
1-4 days
CPT Code:
86617x2
Panel Includes:
Lyme IgG W Blot, Lyme IgG Bands, Lyme IgM W Blot, Lyme IgM Bands, Lyme Western Blot Interpretation
