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Get LA Lab Form 96 2013-2024

Lab Form 96 Revision 09/2013 Lab Test Request Form VIROLOGY / IMMUNOLOGY BOLD PRINT INDICATES REQUIRED INFORMATION. INCOMPLETE INFORMATION MAY CAUSE SPECIMEN REJECTION. Patient Information First Name Last Name Middle Initial Date of Birth / Address City State Zipcode Parish Marital Status Gender Race Divorced Widowed Male AI - American Indian/Alaskan Native AP- Asian Pacific Married Unknown Female BL - Black/African American MR - More than One Separated Other PI - Pacific Islander/Native Hawaiian OT - Other WH - White/Caucasian UK - Unknown/Unreported Hispanic Single Medicaid Number Chart Number Medical Provider Name Bayou Health Plan Name Bayou Health Identification Number Clinic Type or OPH Code For test information see www. lab. dhh. louisiana.gov or email questions to oph. publichealthlab la.gov Specimen Information Influenza Real Time RT-PCR Hepatitis B Mumps Vaccination Date Respiratory Virus Panel Hepatitis B Immunization Dengue Risk Factors Norovirus GI and GII Orthopox Arbovirus Panel Rubella MERS-CoV Date of Collection Time Tissue Frozen Date and Time Specimen Type Swab Specimen Source Nasal Nasopharynx Trachea Blood Vomitus Oropharynx Bronchii CSF Stool Serum Acute / Convalescent Submitter Information Aspirate/Wash Viral Culture Original Material If you know your StarLims Facility Identification Number enter it here. Facility Name Optional - Facility Stamp Facility Address Contact Person Phone/Fax Ship Specimens to DHH-OPH Central Lab 1209 Leesville Avenue Baton Rouge LA 70802 TO BE COMPLETED BY STATE LABORATORY LABORATORY NUMBER TEMPERATURE DATE/TIME RECEIVED STAMP TUBE EXPIRATION Collection Tube Viral Transport. Lab Form 96 Revision 09/2013 Lab Test Request Form VIROLOGY / IMMUNOLOGY BOLD PRINT INDICATES REQUIRED INFORMATION* INCOMPLETE INFORMATION MAY CAUSE SPECIMEN REJECTION* Patient Information First Name Last Name Middle Initial Date of Birth / Address City State Zipcode Parish Marital Status Gender Race Divorced Widowed Male AI - American Indian/Alaskan Native AP- Asian Pacific Married Unknown Female BL - Black/African American MR - More than One Separated Other PI - Pacific Islander/Native Hawaiian OT - Other WH - White/Caucasian UK - Unknown/Unreported Hispanic Single Medicaid Number Chart Number Medical Provider Name Bayou Health Plan Name Bayou Health Identification Number Clinic Type or OPH Code For test information see www. lab. dhh. louisiana*gov or email questions to oph. publichealthlab la*gov Specimen Information Influenza Real Time RT-PCR Hepatitis B Mumps Vaccination Date Respiratory Virus Panel Hepatitis B Immunization Dengue Risk Factors Norovirus GI and GII Orthopox Arbovirus Panel Rubella MERS-CoV Date of Collection Time Tissue Frozen Date and Time Specimen Type Swab Specimen Source Nasal Nasopharynx Trachea Blood Vomitus Oropharynx Bronchii CSF Stool Serum Acute / Convalescent Submitter Information Aspirate/Wash Viral Culture Original Material If you know your StarLims Facility Identification Number enter it here. .

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