HLA Testing Service Request – Disease Association

Ordering Physician / Laboratory
SBC bills the physician/physician's facility. SBC does not bill patients or patients' insurance providers.
Requesting entity:
Ordering physician: *

First Name Last Name
Clinic/lab address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Department:
ICD-10:
ICD-10 diagnostic insurance codes NOT required for Kaiser patients; Suggested for all other patients.
UPIN#:
Ordering physician phone:
Please enter a valid phone number.
Ordering physician FAX:
Please enter a valid phone number.
Ordering physician email: *
Reports will be sent as attachments via secure email unless otherwise requested. Contact HLAsupport@lists.stanford.edu for help.

Specimen Information
STANFORD SPECIMENS:
Send to clinical lab for transport.
Non-STAT samples must be received by 1:00 p.m. on Fridays.
Specimen source:

Peripheral Blood (one yellow-top ACD tube required); (Pediatric: 3ml) Pre-Extracted DNA Buccal Swab Specimen in lab
Additional services: *

DNA extraction and storage(must be checked if submitting buccal swab or blood for typing; charges will apply) Other
Draw date:

Month Day Year
Date
Draw time:
Phlebotomist initials:
What is the interest in or purpose for the test? This information will be used as guidance for results interpretation (e.g., "to confirm...," "to rule out...," etc.)
Any Additional Comments or Considerations:
Should be Empty:

HLA Disease Association Testing Order Form