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DIAGNOSTIC AUTOANTIBODY REQUESTBARBARA DAVIS CENTER FOR CHILDHOOD DIABETESUniversity of Colorado School of Medicine, Anschutz Medical Campus1775 Aurora Ct, M20-4201EAurora, CO 80045Phone: (303) 724-6809FAX: (303) 724-5811DIRECTIONS FOR SENDING SAMPLES FOR AUTOANTIBODY MEASUREMENTPlease complete the diagnostic islet autoantibody request form. Make sure you include an address where the results should be sent.A 3-cc tube (red-top or tiger-top) of blood should be drawn.Blood should be allowed to clot and tube should be centrifuged.Serum should be removed and transferred to a vial labeled with the patient’s full name and the date the sample is drawn.Vial containing serum should be sent by overnight mail with cool pack to:Attn: Diagnostic SampleBarbara Davis Center1775 Aurora Ct. M20-4201EAurora, CO 80045Tel: 303-724-6809The results of the test will be reported within a week. GAD Autoantibodies (GAA)……...$40.00 Complete Islet Autoantibody screen(CPT 83519) (GAA, IA-2, IAA, ZnT8)......……………..…...$120.00 (CPT 83519,86341,86337,86849) IA-2 Autoantibodies (IA-2)….........$40.00 Transglutaminase Autoantibodies (Tg) (CPT 86341) (Celiac disease, CPT83516)......................................$40.00 21-Hydroxylase Autoantibodies (Hyd21) Insulin Autoantibodies (IAA)..........$60.00 (Addison’s disease, CPT83519)................................$40.00(CPT 86337) Complete Islet Autoantibody plus 21-Hydroxylase, Transglutaminase Autoantibodies.................$160.00 Znt8 Autoantibodies (ZnT8)............$40.00 (CPT 83519,86341,86337,83516,83519,86849) (CPT 86849)______________________________________________________________________________________________________________________ APatient Name: _________________________Clinic/Hospital ID# _________________________Date of Birth: _________________________Sample Drawn Date __________________________________________________________________________________________________________________B Requesting physician or clinic will be billed for this test.Requesting Physician: _____________________ Billing Address:___________________________Address:______________________ _________________________________________________ ___________________________ Phone:______________________Phone:____________________Fax:______________________Fax:___________________________________________________________________________________________________________RESULTSSend results to (circle one): A BGAA:__________ IA-2:__________ IAA: __________ ZnT8: _________ Tgase: _________ Hyd21: __________ normal< 20 normal < 5 normal < 0.011 normal < 0.021 normal <0.050 normal< 0.150 elevated > 25 elevated > 7 elevated > 0.013 elevated > 0.030 elevated >0.100 elevated 0.200Date Report:________________ ................
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