Mold IV Allergen Panel
| 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. Mold IV Allergen Panel | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
MOLD
Test Workstation :
MAYO
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
6.0 mL
Minimum Volume:
4.0 ml
Storage:
Refrigerated
Availability:
Sent to Mayo Medical Laboratory
Methodology:
Fluorescence Enzyne Immunoassay ( FEIA)
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Reference range is available on patient report
CPT Code:
86003
Profile Includes:
Trichosporon Pllulans IgE, Cephalosporium Acremonium IgE, Mucor IgE, Candida Albicans IgE, Stemphyllium IgE, Trichophyton Rubrum IgE, Phoma Betae IgE, Helminthosporium IgE, Fusarium Moniliforme IgE, Curvularia Lunata IgE, Epicoccum Purpurascens IgE, Rhizopus Nigricans IgE, Alternaria Tenuis IgE, Aspergillus Fumigatus IgE, Cladosporium IgE, Penicillium IgE, Aspergillus niger, IgE
