STANDING ORDER
UCDHS
Order Start Date: ___________________
Order End Date: ___________________
Frequency: ____________________
Physician Signature:
Laboratory
Referring Physician:
Medical Record or Patient ID # or Specimen #
Patient SS #
Male
M
Female
Age
Birthdate
STAT
F
Patient Address
BILL TO 
City
State
Zip
Phone #
Start Date:
Time:
Patient Weight:
Finish Date:
Time:
Height:
TESTS
Fasting
TS
APTT
AMM
ANA
BMP
BHCGONT
CA125
BC
CBC
CK
CA
CMP
CR
CC
ES
FER
FOL
FSH
G
GTT1
GTT2
HIVS
THOM
HGBA1C
HEPPAN
AUSAB
HAVAB
HAVABM
HBSAG
HCV
HEPCLD
Yes
(
Patient
No
HFP
HGB
LP1
LP2
LH
MA
MONO
NBIL
K
PROLAC
PSAM
PSA
Hepatic Panel (Bili-Total, Alkaline Phosp
Protein-Total, AST, ALT, Albumin)
Hemoglobin
Lipid Panel (TC, HDL, Trig, and
Calc. LDL)
Lipid Panel 2 (Direct LDL if trig >400)
Luteinizing Hormone (LH)
Microalbumin Urine, Random
Mono Screen
Neonatal Bilirubin
Potassium
Prolactin
Prostatic Specific Antigen Monitor
Prostatic Specific Antigen Screen
(NOTE: Patient must be age 50 or older. Only one
screen may be ordered in 12 months. Indicate
date of last screen at any facility
If you order a screen (i.e. no disease or symptom
Indicated) for a patient less than 50 years or if it
has been less than 12 months since the last
screen, include an ICD-9, diagnostic narrative or
signed ABN as appropriate.)
PT
RF
ESR
NA
RPR
TSHC
TSHR
FT4C
TESTO
TBIL
UA
UR
UACII
B12
Insurance
Medicare and Medi-Cal will pay only for tests
that meet the Medicare and Medi-Cal
coverage criteria and are reasonable and
necessary to treat or diagnose an individual
patient
TOXICOLOGY
ABO, Rh, Antibody Screen
APTT
Ammonia
Antinuclear Antibody
Basic Metabolic Panel (Glucose,
BUN, Creatinine, Sodium, Potassium,
Chloride, CO2, Calcium)
Beta HCG, Quant
CA 125
CBC – No Diff
CBC – W / Diff
CK, Total
Calcium
Comprehensive Metabolic Panel
(Glucose, BUN, Creatinine, Sodium,
K, Chloride, CO2, Calcium, Protein,
Albumin, Bili-Total, ALP, AST, ALT)
Creatinine, Blood
Creatinine Clearance
MUST also order Blood Creatinine
Estradiol
Ferritin
Folate
Follicle Stimulating Hormone (FSH)
Glucose
1-hour Glucose Load, Dose
2-hour Glucose Load, Dose
Post Meal
HIV Antibody Screen
Homocysteine
Hemoglobin A1C
Hepatitis Acute Panel
(HBsAg, Anti-HCV, Anti-HAVIgM)
Hepatitis B Surface Antibody
Hepatitis A Ab, Total
Hepatitis A Ab, IgM
Hepatitis B Surface Antigen
Hepatitis C Antibody Screen
Hepatitis C Viral Load
A6817 (4/14)
)
)
(
Client
INITIALS
Attach Copy (Both sides) of all the Insurance Cards
Diagnosis & ICD 9 Code:
24 HOUR URINE:
PHONE:
FAX:
DATE / TIME COLLECTED
Protime (INR)
Rheumatoid Factor
SED RATE
Sodium
Syphilis (RPR)
Thyroid Stimulating Hormone (TSH)
TSH REFLEX (If TSH result is less than
0.35 or greater than 5.5 µIUml, a Free T4
test will be ordered)
Thyroxine Free (Free T4)
Testosterone, Total
Total Bilirubin
Urinalysis, complete
TAN
Acid/Neutral GC Screen
TBB
Basic Drug GC Screen
TDS
Comprehensive Drug Screen (Urine)
TDAU
Drugs of Abuse Screen (Urine)
TEG
Ethylene Glycol
TVOL
Volatile GC Screen
THCUR
Cannabinoids Screen (Urine)
TCARB
Carbamazepine
TCYCLO
Cyclosporine
DIG
Digoxin
TFK506
FK 506
TLDB
Lead, Blood
TLI
Lithium
TMTX
Methotrexate
TPHENO
Phenobarbital
TDPH
Phenytoin
TVPA
Valproate
TVANCO
Vancomycin – (PK, TR, or RND) *
* Please circle Peak (PK), Trough (TR), or Random
(RND)
RUBELIGG
Rubella Ab, IGG
RUBEOIGG
Rubeola Ab, IGG
VZIGG
Varciella Zoster Ab, IGG
MUMPSIGG
Mumps Ab, IGG
MICROBIOLOGY
SOURCE:
MPGP
BSRVAG
BSTH
GC & Chlamydia DNA Probe
___ Genital? ___ Urine?
Screening Group B Strep
Rectovaginal / OB pt S only
Culture, Beta Strep Group A
Throat only.
Culture, routine Bacteriology
Gram Stain
Culture, Fungal
Culture, Stool (sal., shig. campy)
or other enteric pathogen
(specify)
FADCG
Cryptosporidium & Giardia only
OP
O & P Stool, routine x
CDT
Clostridium Difficile Toxin
Fresh Stool
Culture, Other (specify)
HSV
Acid Fast Smear
Culture, HSV only
Culture, routine Viral
Viral EIA/Immunofluorescence
Agents:
Source:
ADDITIONAL TEST(S) & COMMENTS
clean catch
cath
Urine Culture
clean catch
cath
Urinalysis with a Culture If Indicated
(Note: submit urine in urine culture
transport tube in addition to urine for
urinalysis.)
Vitamin B12
ORIGINAL – FORWARD TO CLIENT SERVICES
916-734-7373
1-800-551-9511
Lydia P. Howell, M.D., Director