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Physician

Fax Order Form / Ordering Physician

Physician DR# Client Code

Follow Steps 1-4 for a complete order. Fax orders to 574-807-3010 or 1-866-674-5138

Step 1. DemographicsPatient Name
Last First
DOB SS# / Step 2. Frequency
One time draw: date (if needed)
Standing order (Note: Standing orders are valid for one year.)

Step 3. Mark Tests Needed Step 4. List Diagnosis (DX) or ICD-9 Code For Each Test

090607-1 (1-13)

090607-1 (1-13)

Panel Tests / DX
28192 / Acute Hepatitis Panel
23058 / Electrolyte Panel
35205 / General Health Panel
29525 / Hepatic Function Panel
29048 / Lipid Panel
29526 / Metabolic Basic Panel
29527 / Metabolic Comprehensive Panel
35839 / OB Panel w/Syphilis Scrn by Immunoassay
35842 / OB Panel w/Syphilis Scrn by RPR
29528 / Renal Function Panel
Individual Tests / DX
29109 / Amylase
29021 / BUN
30225 / Ca 125
29039 / Calcium
25517 / CBC with Diff
25014 / CBC without Diff
30181 / CEA
/ Individual Tests / DX
29241 / Cholesterol, Total
29131 / Creatinine
31042 / Digoxin
30055 / Ferritin
29129 / Glucose
30089 / HCG, Qualitative
23409 / Hemoglobin A1C
28270 / HIV-1/2 Ab Screen
29100 / Iron includes (TIBC)
23084 / Magnesium
29168 / Phosphorus
29127 / Potassium
23119 / Protein, Total
25045 / Prothrombin Time (PT)
30178 / PSA, diagnostic
30078 / PSA, screening
25230 / Sed Rate
29255 / SGOT (AST)
/ Individual Tests / DX
29152 / SGPT (ALT)
29028 / Sodium
30016 / T3, Free
30113 / T4, Free
30213 / T4, Total
30017 / TSH
25074 / UA w/Micro. C&S if ind
25075 / Urinalysis w/Microscopic
21054 / Urine C&S, clean catch (sens if ind)
31032 / Valproic Acid
(Depakote)
Additional Tests / DX
Optional Stat Phone Fax
Copy to
Special Instructions:
Fasting?

Faxed by Date/Time


Individual Tests Included in Panels

Panel
Test / Order
# / Individual Tests
Included
Acute Hepatitis Panel / 28192 / Hepatitis A IgM Antibody
Hepatitis B Core IgM Antibody / Hepatitis B Surface Antigen w/ Confirmation if indicated
Hepatitis C Antibody
Electrolyte Panel / 23058 / Carbon Dioxide
Chloride
Potassium / Sodium
Anion Gap (calculated)
Hepatic Function Panel / 29525 / Albumin
Alkaline Phosphatase
ALT (SGPT)
AST (SGOT) / Bilirubin, Direct and Total
Protein, Total
Albumin/Globulin Ratio (calculated)
Globulin (calculated)
Lipid Panel / 29048 / Cholesterol, Total
Triglycerides
HDL Cholesterol / LDL Cholesterol (calculated)
Total Cholesterol/HDL Ratio (calculated)
Non-HDL Cholesterol (calculated)
Metabolic Basic Panel (BMP) / 29526 / Calcium
Carbon Dioxide
Chloride
Creatine
Glucose / Potassium
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
Metabolic Panel Comprehensive (CMP) / 29527 / Albumin
Alkaline Phosphatase
Bilirubin, Total
Calcium
Carbon Dioxide
Chloride
Creatine
Glucose
Potassium / Protein, Total
SGOT (AST)
SGPT (ALT)
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
Globulin (calculated)
Albumin/Globulin Ratio (calculated
Renal Function Panel / 29528 / Albumin
Calcium
Carbon Dioxide
Chloride
Creatinine
Glucose / Phosphorus
Potassium
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
General Health Panel / 35205 / Albumin
Alkaline Phosphatase
ALT
AST
Bilirubin, Total
Calcium
Carbon Dioxide
Chloride
Creatinine
Glucose / Potassium
Protein, Total
CBC with Diff
Sodium
TSH
Urea Nitrogen (BUN)
A/G Ratio (calc)
Anion Gap (calc)
Globulin (calc)
Obstetric Panel / 35839 / ABO Blood Group and Rh Type
CBC with Automated Differential
HDN RBC Antibody Screen / Hepatitis B Virus Surface Antigen, with CNFRM. if IND.
Rubella IgG Antibody
Treponema pallidum Total Antibodies, by CLIA

090607-1 (1-13)