Employee Health Lab Request Form

The Core Institute Specialty Hospital
6501 North 19th Ave
Phoenix, AZ 85015
Phone: 602-795-6025
Fax: 602-795-6034
Employee Health Lab Request Form

Please include the following Forms with All Testing
2017 Patient Authorization for Disclosure of PHI
2017 Patient Notification Regarding State Mandated Reportable Conditions Form

Patient's Name (Last , First)
Gender
Date of Birth:
Employee Number:
Collection Date:
Collection Time:

Employee Health Testing

6575, 8089, 2341 Measles, Mumps, Rubella (IgG) Panel
2435 Varicella zoster Antibody, IgG
21810 Hepatitis B Surface Antibody, Quantitative
8089 Rubeola (Measles) IgG
6575 Mumps Virus Antibody IgG
2341 Rubella Antibody IgG
21810 Hepatitis B Surface Antibody, Quantitative
8587 Hepatitis C Ab w/Reflex HCV RNA, Quant, RT-PCR

Employee Post Exposure Testing

21810 Hepatitis B Surface Antibody, Quantitative
8587 Hepatitis C Ab w/Reflex HCV RNA, Quant, RT-PCR
3682 HIV 1/2 Ag and Abs, Fourth Generation, w/Reflexes ALL HIV Testing need a seperate tube and Consent Form)
Draw and hold x90 Days (No testing until notified by Employee Health

Post Exposure Source Testing

8020 Hepatitis B Surface Antigen w/Rflx Confirmation
8587 Hepatitis C Ab w/Reflex HCV RNA, Quant, RT-PCR
3682 HIV 1/2 Ag and Abs, Fourth Generation, w/Reflexes (ALL HIV Testing need a seperate tube and Consent Form)