Emory Medical Laboratory
Patient Information (print or use label)
General Laboratory Outpatient Request Form
_____________
Last
Clinic or Hospital Location____________
Contact Number ____________________
_____________________________________
First
Middle
MRN Number IDX (Clinic):
OR
MRN Number Healthquest (Hospital): _________________
Contact Number_____________________
Physician Signature Required
_________________________________________
Today’s Date_____________
To be Collected NOW or Specific Date ________
Date of Birth:
Sex: M / F
Requesting Physician___________________________________________
Last
First
M.
Diagnosis Codes
To Meet Federal Compliance Standards, ICD-9 Code(s) are required
Specimen Collection Information
1. _________________________ 2.______________________________
Collected by _______________ Date___________ Time__________
3. _________________________ 4. ______________________________
When ordering tests for which reimbursement will be sought, physicians should only order tests which are medically necessary for the diagnosis or treatment.
Asterisk (*) denotes tests that will have automatic confirmation performed upon positive screen result unless otherwise indicated.
E M O R Y
1003195
1003197
1004000
1003193
1003199
1000021
1000100
1000200
1001660
1000270
1000790
1001820
1000360
1000620
1001080
1000829
1000720
1000660
1000764
1001612
1503470
9000314
9000313
9007082
1000820
1000024
1001933
1001420
1000940
1503110
1001100
1700400
1001931
1001123
1001803
1001935
1000133
M E D I C A L
Chemistry Profiles
Basic Metabolic (Na, K, Cl,
CO2, BUN, CREAT, GLU, Ca)
Comprehensive Metabolic
(Na, K, Cl, GLU, BUN, CREAT,
TPROT, ALB, Ca, AP, AST,
TBIL, CO2, ALT)
pid Profile (CHOL, TRIG,
HDL, LDL, VLDL)
(FBIL, AP, ALT, AST,
ALB, TPROT)
Renal Profile (Na, K, Cl,
CO2, BUN,CREAT,GLU,
Ca, PHOS, ALB)
Individual Chemistry Tests
AFP Tumor Marker
Alkaline Phosphatase
Amylase
AST
Bilirubin (total)
Bilirubin (total and fractionated)
Blood Bank (use additional form)
BUN (blood urea nitrogen)
Calcium (total)
Cholesterol (total)
Cholesterol, HDL
Cholesterol, LDL Direct
CK (total)
Cortisol
Creatinine
Cyclosporine
Dilantin (phenytoin)
Estradiol, premenopausal
Estradiol, male,child, postmenopausal
Free Estradiol Panel
Ferritin (serum)
Folate
FSH
GGT (gamma GT)
Glucose, GTT, 75 gm
hCG, Quantitative, Serum
Hemoglobin A1c
PTH
Iron & TIBC
Lipase
Lutenizing Hormone, LH
Magnesium
Emory Medical Laboratory
1364 Clifton Road
Atlanta, Georgia 30322
L A B O R A T O R Y
1001480
Phosphorus
1001560
9003120
1001760
1503540
1001800
1001610
1001611
1001780
1001739
1001620
1001740
1001840
1001929
5080400
Prolactin
Testosterone (Free)
Testosterone (Total)
Theophylline
Triglycerides
T3
T4 (Free)
T4 (Total)
reflex to free T4 )
Total Protein
TSH (thyroid stimulating hormone)
Uric Acid
Vitamin B12
Vit-D, 25-OH, Total
Hematology/Coagulation
CBC includes platelet, no diff
Automated Differential
ESR (West sed rate)
Hematocrit
Platelet Count
Protime (PT/INR)
Heparin Assay, anti-FXa
PTT (partial thromboplastin)
2000135
2000110
2000860
2000220
2000257
3000512
3000650
3000431
2000843
Immunology/Serology/Molecular
5020250
ANA Screen
5020260
ANA Screen Plus*
9001163
CCP, Anti CCP, IgG
5080300
CEA
9008106
Celiac Reflexive Panel
9004514
Chlamydia/GC DNA Swab
9005650
Chlamydia/GC DNA Urine
9000910
CMV IgG & IgM
5040245
CRP
3001005
CRP High Sensitivity
5010085
EBV Panel
2501007
G6PD
5080110
Hepatitis A Antibody (IgG and IgM)
9009865
Hepatitis B DNA Quant
5081045
Hepatitis B (diagnostic profile)*
5080020
Hepatitis B Core Antibody
5080013
Hepatitis B Surface Ab Quant
(Anti HBS)
5080000 Hepatitis B Surface Antigen*
5080075 Hepatitis C Antibody*
9009862 Hepatitis C (Quantitative) PCR
9004422 Hepatitis C Genotype PCR
5010046 Herpes Simplex I & II Antibody, IgG
5080001 HIV Antigen / Antibody
James Ritchie, PhD, Director Emory Medical Laboratory
John Roback, MD, PhD, Vice Chair and Director of Laboratory Medicine
9005102
5040581
HIV Quant, HIV-1 RNA viral load
Immunoglobulin Quant, IGQUANT
PSA, Screen
PSA
1000659 PSA, Free & Total
1504620 RF (Rheumatoid Factor)
5080200 RPR (rapid plasma reagin)*
5050504 Serum Protein Electrophoresis, SPE
Urine Test
Random
24 Hour
Amylase
1000230
1500222
Microalb/Cr Ratio
5040040
Calcium
1000390
1001381
CA/Creat Ratio
1099941
Creatinine
1001940
1000759
Creatinine Clr
1503149
Protein
1001917
1000920
Sodium
1001720
1001538
1504530 Urinalysis, Routine
1504540 Urinalysis, Microscopic
hCG Pregnancy Screen, urine
Microbiology
6011100
6000501 Blood Culture, Routine
6000579 C. Difficile Toxin, Feces
6000511 Feces (Stool) Culture
6011040 Feces, Occult Blood circle one X1 X3
6000521 Feces, Ova & Parasites
6000465 Group A Strep Screen
6000573
6000464 MRSA Culture, Screen
6000514
9004020
6000536 Urine Culture & Sensitivity
6000524 Wound/Abscess Culture, superficial
(aerobic only)
Specific Body Site: _______________
6000529 Wound/Abscess Culture, deep wound
(aerobic and anaerobic)
Specific Body Site: _______________
Other Tests
Phone Number: 404-712-5227
Fax: 404-712-0828
Revised 2/2013