BLOOD BANK OUTPATIENT REQUEST FORM - University of Virginia

BILLING ACCOUNT # (ATTACH LABEL, IF AVAILABLE)
BLOOD BANK OUTPATIENT REQUEST FORM
FOR LAB USE ONLY
SPECIMEN(S) RECEIVED:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
ACCN#______________________________________________________
PATIENT NAME (LAST, FIRST, MI) - PLEASE PRINT SEX PATIENT HISTORY # DOB
M
F
Typenex
Label
Previous Record
PHYSICIAN NAME (LAST, FIRST) PHONE / PIC # PHYSICIAN SIGNATURE PATIENT LOCATION DATE & TIME OF COLLECTION
CHECK APPROPRIATE BOX FOR BILLING
WHOLESALE ACCOUNT W_____________
INSURANCE BILLING: COMPLETE SECTION 1-6 BELOW
PATIENT BILLING (SELF PAY): COMPLETE SECTION 1-2 BELOW
1. PATIENT ADDRESS (STREET OR PO BOX) CITY/STATE ZIP CODE
2. PATIENT PHONE # PATIENT SOCIAL SECURITY # PATIENT MARITAL STATUS RACE
S M W D S M OTHER
GUARANTOR NAME (LEAVE BLANK IF PATIENT IS GUARANTOR) GUARANTOR PHONE# RELATIONSHIP TO PATIENT
GUARANTOR ADDRESS (STREET OR PO BOX) CITY/STATE ZIP CODE
3. MEDICARE: PRIMARY/SECONDARY MEDICARE 3 & LETTER 4. MEDICAID # STATE EFFECTIVE DATE
5. OTHER INSURER COMPANY NAME ADDRESS PHONE #
EFFECTIVE DATE SUBSCRIBER NAME POLICY # GROUP #
6. LONG TERM AGREEMENT (Must be signed by the patient)
I hereby assign the benefits of my insurance policy to the University of Virginia Medical Center (the “Medical Center”) and the University of Virginia Health Services Foundation (the “Foundation”)
as appropriate. I understand that I am responsible for all charges that are not paid by that policy. I authorize the medical Center and the Foundation to release to the health Care Financing
administration and/or my insurance company any and all information needed in order to consider payment of my claim for services rendered. (The term “insurance” refers to any and all types of
health care coverage, including but not limited to Medicare, Medigap, and CHAMPUS.)
I understand that this assignment and authorization will remain in effect indefinitely or until such a time that i give written notice to the contrary.
Date___________________________ Signature______________________________________________________________________________________________________________________
NOTE: When ordering tests in which Medicare reimbursement will be sought, Physicians should only order tests which are medically necessary for the diagnosis or treatment. Tests in red ink may
be denied by Medicare. Patient should be given ABN to sign. see back of top copy. each desired test included in one of the Shaded-Area Panels must be checked individually to meet
Federal medical necessity requirements. *Denotes tests that will have automatic confirmation performed upon positive screen result unless otherwise indicated.
BLOOD BANK TESTS
ICD-9 CODE TEST NAME TEST CODE
___________ TYPE & HOLD FOR
COMPATIBILITY TEST
ABO & Rh
ANTIBODY SCREEN*
___________ PRENATAL PANEL (TAS)
(order separately)
ABO & Rh
(ABRH)
ANTIBODY SCREEN* (ABSCRN)
___________ TRANSPLANT PANEL (TAS)
(order separately)
ABO & Rh
(ABRH)
ANTIBODY SCREEN* (ABSCRN)
___________ PLATELET ANTIBODY PANEL (PLTE)
(order separately)
DIRECT
(PLTD)
INDIRECT
(PLTI)
COMPATIBILITY TEST (PLTXM)
(X-MATCH)
ICD-9 CODE TEST NAME TEST CODE
___________ DIRECT ANTIGLOBULIN* (DCT)
___________ ANTIBODY TITER (TITER)
INDICATION:_____________
___________ RBC ANTIGEN TEST (PAT)
INDICATION:_____________
___________ COLD AGGLUTININS (CAGGT)
___________
OTHER, SPECIFY
________________________
________________________
________________________
ICD-9 CODE TEST NAME TEST CODE
___________ FETAL BLEED SCREEN (RHEV)
INDICATION:____________________
_______________________________
WEEKS GESTATION:_____________
___________ FETAL HEMOGLOBIN (FHSB)
STAIN
___________ DONATH-LANDSTEINER (PCHSB)
___________ HAM’S TEST (PNHS)
___________ SUCROSE TEST (PNHS)
___________ SERUM VISCOSITY (SVTB)
BLOOD BANK PRODUCTS
ICD-9 CODE PRODUCT NAME QTY DATE NEEDED
____________ RED BLOOD CELLS _________ _________________
____________ FRESH FROZEN PLASMA _________ _________________
____________ PLATELETS _________ _________________
____________ CRYOPRECIPITATE _________ _________________
____________ FIBRIN GLUE _________ _________________
____________ OTHER _________ _________________
ICD-9 CODE
____________
____________
____________
____________
____________
____________
BLOOD BANK SERVICES
SERVICE
CMV REDUCED RISK
IRRADIATED
WASHED
LEUKOCYTE-REDUCED
PROGENITOR CELL PROCESSING
OTHER________________________________________________
Form #33518
To reorder, log onto http://www.virginia.edu.edu/uvaprint/HSC/hs_forms.pl

UNIVERSITY OF VIRGINIA
Health System
Blood Bank and Transfusion Services
Medical Center box 286
Charlottesville, VA 22908
(434) 924-2273
Fax (434) 982-0140
SPECIMEN REQUIREMENTS
Crossmatch (X-Match):
7 mL EDTA lavender top TYPENEX labeled tube, minimum volume 5 mL for adults and 3 mL for children
under two years of age.
ABO/Rh:
7 mL EDTA lavender top tube, minimum volume 5 mL for adults and 3 mL for children under two years of age.
Type and Screen:
7 mL EDTA lavender top TYPENEX labeled tube, minimum volume 5 mL for adults and 3 mL for children under
two years of age.
Direct Antiglobulin Test:
7 mL EDTA lavender top tube.
Antibody Titer:
7 mL EDTA lavender top tube.
Antibody Identification:
7 mL EDTA lavender top tube, minimum volume 7 mL.
Cold Agglutinins: 10 mL plain red top tube and 5 mL EDTA lavender top tube.
NOTE: these tubes must be kept at 37° C!
Platelet Antibody Panel:
10 mL yellow-top tube(s). Call Blood bank to determine how many tubes are needed.
RBC Antigen Testing:
Fetal Bleed Screen:
7 mL EDTA lavender top tube.
7 mL EDTA lavender top tube; post procedure or suspected fetal-maternal bleed.
Fetal Hemoglobin Stain:
7 mL EDTA lavender top tube: suspected fetal-maternal bleed.
Ham’s Test:
Sucrose Test:
4 mL citrated blue top tube and 10 mL red top tube.
4mL citrated blue top tube.
Donath - Landsteiner Test:
Call Blood bank to arrange for specimen collection.
Serum Viscosity:
7 mL red top tube.