Spreadsheet: 0bbfd2b6-9cc6-4d9d-ba3d-2569facf0732
Sheet: Sheet2

Patient Name |  |  |  |  |  | Ordering Physician | ____________________________________
Address |  |  |  |  |  | Address _______________________________________________________
City _____________ | State _______________ | Zip |  |  |  | Address_____________________________________________________
Sex    M   F | DOB ______________ | Phone |  |  |  | City ________________ | State _______________ | Zip
INSURANCE/BILLING ANCILLARY FORM MUST BE ATTACHED. |  |  |  |  |  | Phone______________ | Fax__________________
 |  |  |  |  |  | Signature____________________________________________________
ADAMTS13  TESTING | order panel or indv. components |  |  |  |  | COMPLEMENT TESTING | order panel or indv. components
TEST | CPT CODE | SAMPLE TYPE |  |  |  | TEST | CPT CODE | SAMPLE TYPE
ADAMTS13 PANEL * | 85397+85335+85320 | PPP |  |  |  | COMPLEMENT PROFILE | 86160X15 | SER
ADAMTS13 ACTIVITY* | 85397 | PPP |  |  |  | C2-COMPLEMENT | 86160 | SER
ADAMTS13 INHIBITION TEST * | 85335 | PPP |  |  |  | [NAME] | 86160 | SER
ADAMTS13 ANTIBODY QUANT | 85320 | SER/P |  |  |  | C4-COMPLEMENT | 86160 | SER
* SEE SAMPLE PREP INSTRUCTIONS* |  |  |  |  |  | C5-COMPLEMENT | 86160 | SER
CLINICAL INFORMATION IF AVAILABLE |  |  |  |  |  | C6-COMPLEMENT | 86160 | SER
Is the patient receiving plasma infusion or plasmapheresis (Yes/No)? |  |  |  |  |  | C7-COMPLEMENT | 86160 | SER
If Yes, date of last plasma infusion or plasmapheresis? |  | ____________ |  |  |  | C8-COMPLEMENT | 86160 | SER
Schistocytes | (Yes/No)? |  |  |  |  | C9-COMPLEMENT | 86160 | SER
PT/PTT |  |  |  |  |  | FACTOR B | 86160 | SER
LDH |  |  |  |  |  | C1 ESTERASE INHIBITOR | 86160 | SER
Haptoglobin |  |  |  |  |  | FACTOR I | 86160 | SER
[NAME] |  |  |  |  |  | FACTOR H | 86160 | SER
Creatinine |  |  |  |  |  | C1q | 86160 | SER
 |  |  |  |  |  | PROPERDIN | 86160 | SER
 |  |  |  |  |  | C4 BINDING PROTEIN | 86160 | SER
SERUM PROTEIN | order panel or indv. components
TEST | CPT CODE | SAMPLE TYPE |  |  |  | [NAME] | 86160 x4 | SER
SERUM PROTEIN PROFILE | 82784X3+ 86160X2+ 82040x2 | SER
ALBUMIN | 82040 | SER |  |  |  | [NAME] | 86160 x10 | SER
HS C- REACTIVE PROTEIN | 86141 | SER |  |  |  | [NAME], C3,C5,C6,C7,C8,C9
TRANSFERRIN | 84466 | SER
IGA-IMMUNOGLOBULIN | 82784 | SER |  |  |  | HANE PROFILE/ SLE PROFILE | 86160x4 | SER
IGG-IMMUNOGLOBULIN | 82784 | SER |  |  |  | C1 INH, C2,C3,C4
IGM-IMMUNOGLOBULIN | 82784 | SER
[NAME] | 86160 | SER |  |  |  | NUTRITIONAL PROFILE | 86160x4 | SER
C4-COMPLEMENT | 86160 | SER |  |  |  | C3, FAC B,  FAC I, FACT  H
HAPTOGLOBIN | 83010 | SER |  |  |  | CLINICAL INFORMATION IF AVAILABLE
 |  |  |  |  |  | Date of previous kidney biopsy, if any?
IMMUNOGLOBULIN PROFILE | 82784 [NAME] | SER |  |  |  | If previous kidney biopsy was performed, what was the diagnosis?
IGG, IGA, IGM
IGG SUBCLASSES | 82874 + 82787 X4 | SER
IGG, IGG1, IGG2, IGG3 IGG4
 |  |  |  |  |  | aHUS/TTP (TMA) Profile | order panel or indv. components
IGG INDEX | 82784 X2 + 82040 X2 | CSF+SER |  |  |  | TEST | CPT CODE | SAMPLE TYPE
CSF: IGG ALB   SER: IGG,ALB | 82784 |  |  |  |  | ANTI-FACTOR H ANTIBODY | 83516 | SER/P
 |  |  |  |  |  | C3, C4, FAC B,  FAC I, FACT  H | 86160X6 | SER
CYSTATIN C | 82610 | SER |  |  |  | ADAMTS13 | 85397 | PPP
URINARY MICROALBUMIN | 82043 | UR |  |  |  | SHIPPING: | [NAME]
 |  |  |  |  |  | Cincinnati Children's  Hospital Medical Center
RHEUMATOID FACTOR | 86431 | SER |  |  |  | Attention Lab Processing B-4
 |  |  |  |  |  | 3333 Burnet Avenue
ANTI STREPTOLYSIN O | 86060 | SER |  |  |  | Cincinnati Ohio 45229