LABORATORY PLACE LABEL HERE

OUTPATIENT ORDER

PHONE: 678-312-4500

PATIENT NAME: ______SSN ______DOB ______

PHYSICIAN NAME(print): ______SIGNATURE: ______Physician Number______

Medicare: Yes No Pre-certification number if required: ______

A note to all physicians:The procedure will not be performed in the absence of the appropriate diagnosis(s) and/or ICD-9 code(s) supporting the ordered procedure. Ordering physicians are responsible for the accuracy of the information provided.
“RULE OUTS NOT PERMITTED”.
DIAGNOSIS(S) / CLINICAL INFORMATION / SIGNS / SYMPTOMS/ ICD-9 CODES FOR ALL TEST(S) ORDERED:
FAX ORDER TO: 678-442-9736 / CHEMISTRY PANELS / # Prostatic Specific Antigen, Monitoring
# Prostatic Specific Antigen, Screening
# Protime with INR
# PTT
 Theophylline
# TSH (Monitoring)
# TSH (Screening)
 Vitamin B12 level
 Vitamin D level
SEROLOGY/IMMUNOLOGY
 ANA Screen only
 ANA Screen with Reflex testing
 Autoimmune Panel: (includes Anti SSA, SSB: Anti Sm
Anti RNP, SCL70, anti JO, Anti DNA ds,
Anti centromere, Anti histone ab).Please note:
Tests in panel may be ordered separately.
 Rheumatoid Arthritis Factor
CULTURES/URINALYSIS
 Aerobic Wound Culture
Source: ______
 Anaerobic Wound Culture
Source: ______
 Cryptosporidium Specific Antigen, Stool
 Giardia Specific AG, Stool
 Influenza A and B
# Occult Blood  1  2  3
 Ova and Parasites, Stool
 Respiratory Syncytial (RSV) virus
 Rotavirus Antigen, Stool
 Stool culture
# Urine Culture: Cath  Clean Catch
# Urinalysis*:  Cath  Clean Catch
ADDITIONAL TESTS
______
______
______
______
 STAT CALL REPORT: ______
 HOLD patient and CALL:______
 FAX report: ______
# Chem 7 (Basic metabolic Panel)
# CMP (Chem 7, TBA, ALB, TP, AST, AP, ALT, NA, K
CL, CO2, GLU, BUN, CRE)
# Hepatitis Profile (HBAG, HBCG, HAAB, HEPC)
# Lipid Profile (TGL, CHO, HDL, LDL, VLDL)
# Liver Profile TBA, ALB, TP, ALT, AST, AP, DB
 Macrocytic Anemia Profile (VB12, RFOL)
# Renal Profile (Chem 7, PHOS, ALB)
 Southeaster Regional Allergy Panel (SEAL)
# Total Iron Profile (IRON, TFN, SAT)
INDIVIDUAL TESTS
 Amylase
# Bilirubin, Neonatal Total
# Bilirubin, Neonatal Total and Direct
 BNP (B-natriuretic Peptide)
 *CK (Creatinine Kinase)
 C Reactive Protein
# CBC
 # CBC* with Differential (automated)
 Depakote (valproic acid) level
# Digoxin
 Dilantin (phenytoin)
# Ferritin level
 Folate, serum
 Folate, RBC
# Glucose tolerance: gestational  non gestational
# Glyco-Hemoglobin AIC (HGB1)
# H & H
# Hepatitis B Antibody (HBAB)
# *Hepatitis B Surface Antigen (HBAG)
# Hepatitis C antibody (HEPC)
# *HIV (Must submit signed consent)
 Lipase
 Lithium
# Magnesium
 Micro Albumin/Creatinine Ratio, random urine (MALU)
 Platelet Function Assay
# Potassium
 Pregnancy Test, serum (HCGC)
 Pregnancy Test, urine (UHCG)
PLEASE NOTE: # denotes test marked with “#” MUST BE linked to Medicare appropriate diagnosis(s)
*Denotes test marked with Asterisk may reflex to additional testing per Gwinnett Hospital Laboratory protocol or policies

*1-19201* FORM 1-19201 REV. 02/2011 WHITE: Medical Record CANARY: Physician Office Page 1 of 1