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PATIENT INFORMATION Is testing for outpatient Medicare enrollee

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Rev Date 3-16-2021 CLIA # 52D1009037 Medicare Provider # 84481
Versiti does NOT bill patients or their insurance. Call 800-245-3117 ext. 6250 for your Client#.
Person Completing Requisition:
Institution:
Client#
Dept:
Address:
City:
ST:
ZIP:
Phone (Lab): Phone/Email (Provider):
Is testing for outpatient Medicare enrollee or Wisconsin Medicaid recipient? *Yes No
*If YES, please complete the beneficiary form located at www.versiti.org/medical-professionals/products-services/requisitions and submit with this requisition.
Special Reporting Requests:
PO#:
PATIENT INFORMATION
Last Name:
First Name:
MI:
DOB:
MR#:
Accession#:
Draw
Date:
Draw
Time:
Sex: Male Female
Is patient pregnant? Yes No Due / Delivery date: ______________
Has patient had an allogeneic stem cell transplant?
Yes No If yes, send pre-transplant extracted DNA sample
Has patient had a blood transfusion in the last 2 weeks?
Yes No Date and type of transfusion: ____________________
Specimen Type: ACD-A Blood ACD-B Blood Citrated Plasm EDTA Blood Serum (red top) Serum (SST tube) Buccal Swabs
Fetal Specimen Type: Amniotic Fluid Cultured Amniocytes CVS Cultured CVS Cord Blood DNA
Diagnosis Number of Pregnancies Platelet Count______________ Neonate’s Platelet Count_____________
Number of Platelet Transfusions ________ Neutrophil Count _________ Neonate’s Neutrophil Count___________
TEST ORDERS (See reverse side for sample requirements and panel details)
Immune Thrombocytopenias
Drug-Induced Thrombocytopenia (non-heparin)
Immune Thrombocytopenia (ITP)
Drug Dependent Platelet Antibody (9000)
Platelet Autoantibodies (5544) (Sample must be received within 4 days of
To prevent delays in testing, please list drugs to be tested (attach list if needed):
_____________________________________________________________________
draw. See Whole Blood Age Table on page 2.)
Neonatal Alloimmune Thrombocytopenia (NAIT)
Heparin-Induced Thrombocytopenia
Initial testing of Maternal sample with Paternal samples (5603/5703)
Heparin Dependent Platelet Antibody IgG PF4 ELISA (5510)
Father’s Name______________________________ Date of Birth _________
STAT, local customers only. Please call 800-245-3117 ext 6250
Initial testing of Maternal sample ONLY (5303)
Heparin Dependent Platelet Antibody IgA and IgM PF4 ELISA (5514)
Follow up NAIT testing
Heparin-Induced Thrombocytopenia – SRA (5508)
(Order only after 5603 or 5303 have been completed or as advised by BCW)
Heparin-Induced Thrombocytopenia – PEA (5502)
Serial Monitoring of Maternal sample with Paternal Crossmatching (5640)
Heparin-Induced Thrombocytopenia Evaluation – SRA (5509) (test 5510 REFLEX to SRA)
Father’s Name_______________________________ Date of Birth_________
Heparin-Induced Thrombocytopenia Evaluation – PEA (5504) (test 5510 REFLEX to PEA)
Serial Monitoring of Maternal sample ONLY (5630)
Alloimmune Thrombocytopenia
Transfusion Medicine Complications
Platelet Antibody Screen (5543)
Platelet Transfusion Refractory (PTR) Panel (5632)
Platelet Antibody Identification Panel (5608)
Post-Transfusion Purpura (PTP) Panel (5631)
(Includes the Platelet Antibody Screen. Detects antibodies to HPA-1, -2,
(Each panel includes the Platelet Antibody Identification Panel and the Platelet
-3, -4, -5, GPIIb/IIIa, GPIa/IIa, GPIb/IX, GPIV, and Class I HLA)
Antigen Genotyping Panel)
Immune Neutropenias
Alloimmune Neutropenia
Transfusion Related Acute Lung Injury (TRALI)
Neutrophil Antibody Screen (5102)
TRALI Workup on Donor serum (5112) Recipient Name:________________________
Neutrophil Antibody Screen with REFLEX to HLA Antibody Screen (5110)
TRALI Workup on Recipient/Patient serum (5112): Name(s) or unit #(s) of
Neutrophil Antibody Screen with REFLEX to 5113 (5119)
Donors: _______________________________________________________________
Neutrophil Antibody Screen and HLA Antibody Screen (5112)
HOLD TRALI Recipient (5002) Name(s) or unit #(s) of donors: ____________________
Neutrophil Antibody Identification and HLA Antibody Screen (5113)
_______________________________________________________________________
Drug-Induced Neutropenia
Neonatal Alloimmune Neutropenia
Drug Dependent Neutrophil Antibody (9500)
Neonatal Alloimmune Neutropenia (NAN) (5125/5126)
List drugs to be tested: (attach list if needed) __________________________
Father’s Name_________________________________ Date of Birth___________
Genotyping
Platelet Antigen Genotyping (testing for parental/patient/fetal samples)
Neutrophil Antigen Genotyping (testing for parental/patient/fetal samples)
Panel (5600) (HPA-1, HPA-2, HPA-3, HPA-4, HPA-5, HPA-6, HPA-9, HPA -15)
OR
Panel (5201) (HNA-1,HNA-3, HNA-4, HNA- 5)
OR
OR
HPA-1 (5519) HPA-2 (5523) HPA-3 (5520) HPA-4 (5521)
HNA-1 (5250) HNA-3 (5203) HNA-4 (5204) HNA-5 (5205)
HPA-5 (5522) HPA-6 (5524) HPA-9 (5209) HPA-15 (5215)
Immunophenotyping
VERSITI USE ONLY
Glanzmann Thrombasthenia or Bernard Soulier Syndrome
Paroxysmal Nocturnal Hemoglobinuria (PNH)
____EDTA ____Serum
____Amnio ____ACDA
____ACDB ____Clot
____Other _________
Opened By ____
Evaluated By ____
Platelet Glycoprotein Expression (PGE) (5545)
PNH - Leukocytes (5549)
Other
PNH – Erythrocytes & Leukocytes (5550)
Glycoprotein IV (CD36) Typing (5444)
Platelet and Neutrophil Immunology Laboratory
Phone 800-245-3117 x 6250 / Fax (414) 937-6245
Rev Date 3-16-2021 CLIA # 52D1009037 Medicare Provider # 84481
SAMPLE REQUIREMENTS AND SHIPPING INSTRUCTIONS Label samples clearly with full name of individual, date and time drawn.
Test
Sample Requirement
Drug Dependent Platelet Antibody
Drug Dependent Neutrophil Antibody
Heparin-Induced Thrombocytopenia Evaluation (SRA)
Heparin Dependent Platelet Antibody (PF4 ELISA) (IgG, IgA and IgM)
Heparin-Induced Thrombocytopenia (SRA)
NAIT Serial Monitoring of Maternal sample ONLY
Neutrophil Antibody Screen (5102, 5110, & 5119)
Neutrophil Antibody Screen and HLA Antibody Screen
Neutrophil Antibody Identification and HLA Antibody Screen
Platelet Antibody Screen Flow Cytometry
Platelet Antibody Identification Panel
5 ml of serum per test ordered. Sample must be less than 7 days old when tested.
Store refrigerated. Send sample refrigerated. (If the sample has been kept
frozen it may be more than 7 days old.) Send frozen samples on dry ice.
Heparin-Induced Thrombocytopenia (PEA)
Heparin-Induced Thrombocytopenia Evaluation (PEA)
5 ml serum collected at least 3 hours after heparin administration.
Minimum/Pediatric volume: 1mL. Plasma is NOT acceptable for this assay.
Sample must be less than 7 days old when tested. Store refrigerated. Send
sample refrigerated. (If the sample has been kept frozen it may be more than 7
days old.) Send frozen samples on dry ice. Room temperature samples are not
acceptable.
Platelet Glycoprotein Expression (PGE)
5 ml ACD-B or ACD-A whole blood from patient and a control from a volunteer
donor unrelated to patient. Sample must be less than 2 days old when
received. Send FedEx Priority Overnight Mon – Thurs. Send refrigerated.
Platelet Autoantibodies
40 ml ACD-A whole blood if patient platelet count <100,000.
10 ml ACD-A whole blood it patient platelet count >100,000.
See Whole Blood Age Table for draw date and received date requirements.
Send sample refrigerated.
Paroxysmal Nocturnal Hemoglobinuria
PNH – Leukocytes
PNH – Erythrocytes & Leukocytes
5 ml EDTA whole blood. Sample must be less than 2 days old when received.
Send FedEx Priority Overnight Monday – Thursday. Send sample
refrigerated.
Glycoprotein IV (CD36 Typing)
10 ml ACD-A or EDTA whole blood. Send sample at room temperature
TRALI Donor (Transfusion Related Acute Lung Injury)
TRALI Recipient (Transfusion Related Acute Lung Injury)
5 ml serum and 5 ml EDTA whole blood. Send sample refrigerated.
Links/segments are not acceptable
HOLD TRALI Recipient (Transfusion Related Acute Lung Injury)
(Sample will be held for 2 months in the event that HLA or Neutrophil Typing is
wanted. Client is responsible for placing the typing order.)
5 ml EDTA whole blood. Send sample refrigerated.
Links/segments are not acceptable
Neutrophil Antigen Genotyping - Individual or Panel
Platelet Antigen Genotyping - Individual or Panel
3-5 ml EDTA whole blood
7-15 ml amniotic fluid
5 x 10
6
cultured amniotic cells
1 ml Cord Blood
1µg DNA (25ng/µl and 25µl)
3-4 Buccal Swabs
Send sample at room temperature or refrigerated.
Neonatal Alloimmune Thrombocytopenia (NAIT or NATP)
Initial testing on Maternal sample with Paternal sample
(Includes Platelet Antigen Genotyping Panel of mother and father and Platelet
Antibody Identification Panel of mother including crossmatches)
Serial Monitoring testing on Maternal and Paternal samples
(Includes Platelet Antibody Identification Panel of mother including
crossmatches of mother’s serum against father’s platelets)
Initial
Serial Monitoring
Mother
30 ml ACD-A whole blood and
10 ml serum
10 ml serum
Father
30-40 ml ACD-A whole blood
30-40 ml ACD-A whole blood
Each sample must be clearly labeled with the full name of individual (mother
or father).
See Whole Blood Age Table. Send sample refrigerated.
Neonatal Alloimmune Thrombocytopenia (NAIT or NATP)
Initial testing on Only Maternal sample
(Includes Platelet Antigen Genotyping Panel of mother and Platelet Antibody
Identification Panel of mother)
30 ml ACD-A whole blood from mother
10 ml serum from mother
See Whole Blood Age Table for draw date and received date requirements.
Send sample refrigerated.
Post-Transfusion Purpura (PTP)
Platelet Transfusion Refractory (PTR)
5-10 ml EDTA whole blood
10 ml serum
Send sample refrigerated.
Neonatal Alloimmune Neutropenia (NAN)
(Includes Neutrophil Antibody Identification and HLA Antibody Screen on
Mother and Neutrophil Antigen Genotyping Panel of Mother and Father)
5-10 ml EDTA whole blood from mother and father
5-10 ml serum from mother
Send sample refrigerated.
Whole Blood Age Table
Sample drawn on
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Must be received
by
Friday
Friday
Friday
Monday
Tuesday
Wednesday
Thursday
SHIPPING INFORMATION
Ship all samples according to catalog description by Next Day delivery unless specified differently above. If refrigeration is required, use sealed ice packs or wet ice
sealed in plastic bags. Protect whole blood samples from freezing by wrapping in paper toweling. Mark box Refrigerate Upon Arrival. The package must
be shipped in compliance with carrier’s guidelines. Please contact your carrier for current biohazard shipping regulations.
Please call Versiti Client Services (800-245-3117 ext 6255) for advice if you will ship samples near a major holiday.
Shipping Address: Versiti Diagnostic Laboratories / Client Services
638 North 18
th
Street
Milwaukee, WI 53233-2121
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Completed 3 December 2021

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