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Samc.com

Saint Agnes Medical Center
▼ - Patient required to fast for 12-14 hours ● - Patient recommended to fast 12-14 hours Outpatient Center Lab Services
■ - Store at Room Temperature. All other specimens to † - Appointment Required. Call 450-5656 Complete labs ______ weeks/days prior to next appointment.
★ - This test has reflex testing criteria (see reverse side).
To save time, preregister before your lab visit. Call (559) 450-3201 or visit www.samc.com
Please verify that your insurance is accepted by Saint Agnes Medical Center. Ultimately, it is your responsibility to choose
PATIENT:
a laboratory that is contracted with your insurance. If you have any questions, please contact your Insurance carrier.
DIAGNOSIS/PATIENT ORDERING INFORMATION (Additional Codes on Reverse)
All tests for which Medicare reimbursement will be claimed must be medically necessary for the patient.
អ V58.64 Long-term (current) use of non-steroidal អ V58.65 Long-term (current) use of steroids #27 អ V58.69 Long-Term (current) use of Other អ 780.79 Other Malaise & Fatigue #20 Dx / Codes / Signs / Symptoms (For each test ordered below, indicate Dx number on space provided next to test):
Other Dx:

PRIORITY:
អ Copy to _________________________________________________________________________________ អ Phone Results to _________________________________________________________ អ Fax Results to _______________________________________________________________ HEMATOLOGY
CHEMISTRY/IMMUNOLOGY
MICROBIOLOGY
អ@ ★ CBC, Auto Diff (incl. Platelet Ct.)_____ អ អ ★■ Culture & Sensitivity ( Aerobic ) _____ អ ★■ Fungus Culture & Smear _____ អ ■ Rapid Strep A, Culture if Neg _____ @★ Urinalysis, Culture if indicated _____ អ Urines below:
អ ■ Chlamydia/G.C. by DNA Probe _____ អ ▼ Glucose Tolerance, Gestational _____ អ @ Transferrin_____ ● BASIC METABOLIC PANEL _____
OBSTETRICS
COMPREHENSIVE METABOLIC PANEL ___
PRENATAL PANEL _______
Albumin, Alkaline Phosphatase, ALT (SGPT), AST (SGOT), Total Bilirubin, BUN, Calcium, Chloride, CO2, Creatinine, Glucose, Potassium, ELECTROLYTE PANEL _____
HEPATIC FUNCTION PANEL _____
@ - This test may require an Advance Beneficiary Notice (ABN). If so, please attach signed ABN to this order.
Albumin, Alkaline Phosphatase, ALT (SGPT), AST (SGPT), Bilirubin Total, Other Tests / Comments: _________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ @HEPATITIS PANEL, ACUTE _____
___________________________________________________________________________________________________________________________ ▼@LIPID PANEL (CARDIAC RISK) ____
___________________________________________________________________________________________________________________________ RENAL FUNCTION PANEL _____
PRINT Physician's Name
● Albumin, Calcium, CO2, Chloride, Creatinine, Glucose, Phosphorus, Potassium, Sodium, BUN PHYSICIAN'S SIGNATURE ______________________________________________ DATE ______________ SEX M F
THYROID CASCADE
LAB USE ONLY
RACE:_______________
Required Patient Information from Physician *ATTACH COPY OF INSURANCE CARD
Saint Agnes Oakhurst Laboratory
amily Care Providers Laboratory
Saint Agnes F
OAKHURST
CENTRAL FRESNO
KEISHO PLAZA LAB
eachwood Laboratory
Saint Agnes P
Saint Agnes Northwest Laboratory
Saint Agnes Outpatient Center Laboratory
NORTHWEST FRESNO
MAIN HOSPIT
SAINT AGNES LAB
A urine microscopic exam is performed when protein, blood, nitrite and/or Leukocyte Esterase are positive, only at the SAMC Lab Urine Culture is performed when specimen is positive for any or all of the following: Nitrite, Leukocyte, Esterase, and/or Mic TURE IF INDICA
YSIS, CUL
400 mg/dl, a Direct LDL will be added.
T4 is normal, then T3 is added. When TSH is 0.1 - 0.34 or >7.0, then F THYROID CASCADE TESTING: TSH (mcU/ml):
400 mg/dl, a Direct LDL will be added.
ositive HIV antibody screening will be confirmed with HIV antibody by W Y TESTING (WITH CONFIRMA
HIV ANTIB
ositive cultures will be identified & sensitivities performed if appropriate.
ave atypical, unusual, or suspicious cells and/or A manual differential will be ordered when any of the following criteria are met: cell counter indicates that the sample may h UTO DIFFERENTIAL:
ase Autoantibodies, C3, C4, and Rheumatoid F -b, Sm, Scl-70, Sd-70, Ribosomal P Protein, Thyroid P If ANA is positive, reflexes to include dsDNA ANA REFLEX
anel, which includes L/S, PG and Creatinine, is performed. . If screen results are positive there is no further testing.
TURITY SCREEN
AMNIOTIC FL
noted. There will be an additional fee billed for all reflex tests.
Saint Agnes Medical Center's policy provides that the tests listed below will have automatic reflex testing, given the criteria l result generates, or "reflexes", a need for further testing). is the next progression in a sequence of events responding to an abnormal result on the primary test ordered (i.e., the abnorma Reflex testing
REFLEX TESTS
complete listing. The ultimate responsibility for correct coding lies with the ordering physician.
-9 manual for a
it is not complete. Please refer to the ICD
While this list may be a useful reference tool depending upon the nature of your practice, ICD9 DIAGNOSIS CODES
Saint Agnes Medical Center
▼ - Patient required to fast for 12-14 hours ● - Patient recommended to fast 12-14 hours Outpatient Center Lab Services
■ - Store at Room Temperature. All other specimens to † - Appointment Required. Call 450-5656 Complete labs ______ weeks/days prior to next appointment.
★ - This test has reflex testing criteria (see reverse side).
To save time, preregister before your lab visit. Call (559) 450-3201 or visit www.samc.com
Please verify that your insurance is accepted by Saint Agnes Medical Center. Ultimately, it is your responsibility to choose
PATIENT:
a laboratory that is contracted with your insurance. If you have any questions, please contact your Insurance carrier.
DIAGNOSIS/PATIENT ORDERING INFORMATION (Additional Codes on Reverse)
All tests for which Medicare reimbursement will be claimed must be medically necessary for the patient.
អ V58.64 Long-term (current) use of non-steroidal អ V58.65 Long-term (current) use of steroids #27 អ V58.69 Long-Term (current) use of Other អ 780.79 Other Malaise & Fatigue #20 Dx / Codes / Signs / Symptoms (For each test ordered below, indicate Dx number on space provided next to test):
Other Dx:

PRIORITY:
អ Copy to _________________________________________________________________________________ អ Phone Results to _________________________________________________________ អ Fax Results to _______________________________________________________________ HEMATOLOGY
CHEMISTRY/IMMUNOLOGY
MICROBIOLOGY
អ@ ★ CBC, Auto Diff (incl. Platelet Ct.)_____ អ អ ★■ Culture & Sensitivity ( Aerobic ) _____ អ ★■ Fungus Culture & Smear _____ អ ■ Rapid Strep A, Culture if Neg _____ @★ Urinalysis, Culture if indicated _____ អ Urines below:
អ ■ Chlamydia/G.C. by DNA Probe _____ អ ▼ Glucose Tolerance, Gestational _____ អ @ Transferrin_____ ● BASIC METABOLIC PANEL _____
OBSTETRICS
COMPREHENSIVE METABOLIC PANEL ___
PRENATAL PANEL _______
Albumin, Alkaline Phosphatase, ALT (SGPT), AST (SGOT), Total Bilirubin, BUN, Calcium, Chloride, CO2, Creatinine, Glucose, Potassium, ELECTROLYTE PANEL _____
HEPATIC FUNCTION PANEL _____
@ - This test may require an Advance Beneficiary Notice (ABN). If so, please attach signed ABN to this order.
Albumin, Alkaline Phosphatase, ALT (SGPT), AST (SGPT), Bilirubin Total, Other Tests / Comments: _________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ @HEPATITIS PANEL, ACUTE _____
___________________________________________________________________________________________________________________________ ▼@LIPID PANEL (CARDIAC RISK) ____
___________________________________________________________________________________________________________________________ RENAL FUNCTION PANEL _____
PRINT Physician's Name
● Albumin, Calcium, CO2, Chloride, Creatinine, Glucose, Phosphorus, Potassium, Sodium, BUN PHYSICIAN'S SIGNATURE ______________________________________________ DATE ______________ SEX M F
THYROID CASCADE
LAB USE ONLY
RACE:_______________
Required Patient Information from Physician *ATTACH COPY OF INSURANCE CARD
Saint Agnes Oakhurst Laboratory
amily Care Providers Laboratory
Saint Agnes F
OAKHURST
CENTRAL FRESNO
KEISHO PLAZA LAB
eachwood Laboratory
Saint Agnes P
Saint Agnes Northwest Laboratory
Saint Agnes Outpatient Center Laboratory
NORTHWEST FRESNO
MAIN HOSPIT
SAINT AGNES LAB
A urine microscopic exam is performed when protein, blood, nitrite and/or Leukocyte Esterase are positive, only at the SAMC Lab Urine Culture is performed when specimen is positive for any or all of the following: Nitrite, Leukocyte, Esterase, and/or Mic TURE IF INDICA
YSIS, CUL
400 mg/dl, a Direct LDL will be added.
T4 is normal, then T3 is added. When TSH is 0.1 - 0.34 or >7.0, then F THYROID CASCADE TESTING: TSH (mcU/ml):
400 mg/dl, a Direct LDL will be added.
ositive HIV antibody screening will be confirmed with HIV antibody by W Y TESTING (WITH CONFIRMA
HIV ANTIB
ositive cultures will be identified & sensitivities performed if appropriate.
ave atypical, unusual, or suspicious cells and/or A manual differential will be ordered when any of the following criteria are met: cell counter indicates that the sample may h UTO DIFFERENTIAL:
ase Autoantibodies, C3, C4, and Rheumatoid F -b, Sm, Scl-70, Sd-70, Ribosomal P Protein, Thyroid P If ANA is positive, reflexes to include dsDNA ANA REFLEX
anel, which includes L/S, PG and Creatinine, is performed. . If screen results are positive there is no further testing.
TURITY SCREEN
AMNIOTIC FL
noted. There will be an additional fee billed for all reflex tests.
Saint Agnes Medical Center's policy provides that the tests listed below will have automatic reflex testing, given the criteria l result generates, or "reflexes", a need for further testing). is the next progression in a sequence of events responding to an abnormal result on the primary test ordered (i.e., the abnorma Reflex testing
REFLEX TESTS
complete listing. The ultimate responsibility for correct coding lies with the ordering physician.
-9 manual for a
it is not complete. Please refer to the ICD
While this list may be a useful reference tool depending upon the nature of your practice, ICD9 DIAGNOSIS CODES

Source: http://www.samc.com/documents/OfficeStaff/Outpatient_Center_Lab_Services_Referral_Form.pdf

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