ࡱ> m ybjbj ?;j;jy -----t|4(@Q(yyyy'''''''_*-'--'--yy' .-y-y:&p ' :j%,%y@][^% &&'0(%R->F-%--%4 ''(-Y : DIAGNOSTIC AUTOANTIBODY REQUEST BARBARA DAVIS CENTER FOR CHILDHOOD DIABETES University of 鶹ý School of Medicine, Anschutz Medical Campus 1775 Aurora Ct, M20-4201E Aurora, CO 80045 Phone: (303) 724-6809 FAX: (303) 724-5811 DIRECTIONS FOR SENDING SAMPLES FOR AUTOANTIBODY MEASUREMENT Please complete the request form. Make sure to include an address where the results should be sent. A 3-cc tube (red-top or tiger-top) of blood should be drawn, allowed to clot, and centrifuged. At least 250uL of serum should be transferred to a vial labeled with patients full name and the date of draw. If the sample will be held longer than one day prior to shipping, freeze sample and ship on dry ice. Samples cannot be tested if extremely hemolyzed or lipimic. No frozen whole blood samples. Vial containing serum should be packaged with a cool pack or on dry ice (if frozen). Send by overnight mail to: Attn: Diagnostic Sample Barbara Davis Center 1775 Aurora Ct. M20-4201E Aurora, CO 80045 Tel: 303-724-6809 The results of the test will be reported within 1-2 weeks. GAD65 Autoantibodies (GADA)..$70.00 o Complete Islet Autoantibody screen (CPT 83519) (GADA, IA-2A, IAA, ZnT8A) $230.00 (CPT 83519,86341,86337,86341) IA-2 Autoantibodies (IA-2A)........$70.00 o Transglutaminase Autoantibodies (TGA) (CPT 86341) (Celiac disease, CPT 83516) $70.00 o 21-Hydroxylase Autoantibodies (Hyd21) Insulin Autoantibodies (IAA)..........$120.00 (Addisons disease, CPT83519) $70.00 (CPT 86337) o Complete Islet Autoantibody plus 21-Hydroxylase, Transglutaminase Autoantibodies $315.00 o ZnT8 Autoantibodies (ZnT8A).............$70.00 (CPT 83519,86341,86337,83516,83519,86341) (CPT 86341)  A Patient Name: Date of Birth: Clinic/Hospital ID#: Sample Drawn Date:  SHAPE \* MERGEFORMAT  B Requesting physician or clinic will be billed for this test. Requesting Physician: Billing Address: _ _ _ Address:   SHAPE \* MERGEFORMAT  Phone: Fax: Phone: Fax: RESULTS GADA:  IA-2A: IAA:  ZnT8A:  TGA: Hyd21: normal d" 20 Version 8 normal d" 5 normal d" 0.010 normal d" 0.020 normal d" 0.050 normal d" 0.150 01/02/2025 Report Date This test was developed and its performance verified by the Autoantibody Laboratory at the Barbara Davis Center. It has not been cleared or approved by the US Food and Drug Administration. Brief descriptions of the method and performance characteristics are available upon request. This laboratory is certified under the Clinical Laboratory Improvement Amendments (CLIA) and the College of American Pathologists (CAP) as qualified to perform high complexity clinical laboratory testing.  KL ! 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P0- @Times New Roman--@Times New Roman------  2 X%0   - - @Times New Roman-- - - - - @Times New Roman---- - "Arial- -  - @Times New Roman- - @Times New Roman-!- !- - - - - - @Times New Roman-- - - - @Times New Roman-- - - - - - - @Times New Roman-- - @Times New Roman-- @Times New Roman-- - - @Times New Roman-- -  2 l00 Patient  2 lV0   2 lW0 Name:  - - -   2 l|0  - - @Times New Roman-- -  @Times New Roman--  2 l0  - - -   2 l0    2 l(0  @Times New Roman---- - "Arial-!- !- @Times New Roman-!-!@Times New Roman-"-!"-!@Times New Roman----" @ !m-"  0''- - @Times New Roman-"- "- - - - - - @Times New Roman-"- "- - - - - - @Times New Roman-"- "- @Times New Roman-"- "@Times New Roman-"- "- - @Times New Roman-"- "-  2 00 Date of   2 Y0   2 [0 Birth: - - -   2 z0    2 }0  - - @Times New Roman-"- "-  @Times New Roman-"- " 2 0  - - -   2 0    2 (0    2 -0  -" @ !-"  0''@Times New Roman-"-"-"  0''- - @Times New Roman-#- #- - - - - - @Times New Roman-#- #- - - - - - @Times New Roman-#- #- - - - - - @Times New Roman-#- #- @Times New Roman-#- #@Times New Roman-#- #- - @Times New Roman-#- #-  "2 mM0 Clinic/Hospital    2 m0   2 m0 ID#: - - -   2 m0  - - @Times New Roman-#- #-  @Times New Roman-#- # 2 m0  - - -   2 m0    2 mj0  -# @ !n-#  0''- - @Times New Roman-#- #- - - - - - @Times New Roman-#- #- - - - @Times New Roman-#-#-#- - @Times New Roman-$- $-  @Times New Roman-$- $2 P 0 Sample Drawn     2 0   2 0 Date: - - -   2 0  - - @Times New Roman-$- $-  @Times New Roman-$- $ 2 0  - - -   2 0    2 j0  -$ @ !-$  0''@Times New Roman-$-$-$  0'-$-$-$  2 0   --@Times New Roman-%-%---@Times New Roman-%-%-@Times New Roman-%-%@Times New Roman-%-%--@Times New Roman-%-%-  2 00 B   2 90   \2 60 Requesting physician or clinic will be billed for this    2 0   2 0 test.---  2 0  -% @ ! 0-%-% @ !=-%  0''@Times New Roman-%-%-%  2 %0   - - @Times New Roman-&- &- @Times New Roman-&- &@Times New Roman-&- &- - @Times New Roman-&- &-  2 0 0 Requesting   2 l0   2 o 0 Physician:  2 0    2 0    2 90  H 2 0 Billing   2 0   2 0 Address:   2 0    2 0    2 0 _  2 0    2 0  Y  2 V0 _  2 ]0    2 `0  %  2 0 _- - -   2 0  @Times New Roman-&-&-&- - "Arial-'- '- @Times New Roman-'-'@Times New Roman-(-'(-'&-& @ !-&-& @ !-&-& @ !\-&-& @ !(]-&  0''@Times New Roman-&-'&@Times New Roman-&-'&@Times New Roman-&-'&---  2 %0   - - @Times New Roman-&- &- - - - - - @Times New Roman-&- &- - - - - - - - - @Times New Roman-&- &- - - - - - @Times New Roman-&- &-  @Times New Roman-&- &2 00 Address: - - -   2 _0  G- - @Times New Roman-&- &-  @Times New Roman-&- & 2 0  - - -   2 0    2 :0  - - @Times New Roman-&- &-  @Times New Roman-&- & 2 0  - - -   2 0    2 0  -& @ !-&-& @ !-&  0''@Times New Roman-&-&-&  2 %0   @Times New Roman-(-(-(  2 %0    -$-$-$ 0'-$-$-$  2 ;0   @Times New Roman-)-)-)  2 %0   - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 00 Phone:- - -   2 V0  P- - @Times New Roman-*- *-  @Times New Roman-*- * 2 0  - - -   2 0    2 ;0  -* @ !!-*  0''- - -   2 /%0   - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 =00 Fax:- - -   2 =I0  ]- - @Times New Roman-*- *-  @Times New Roman-*- * 2 =0  - - -   2 =0    2 =;0  -* @ !>-*  0''  0''- - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- * 2 0 Phone:  2 0  -  2 0    2 0    2 0  -* @ !!-*  0''- - @Times New Roman-*- *- - - - - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 90 Fax:- - -   2 90  9- - @Times New Roman-*- *-  @Times New Roman-*- * 2 90  - - -   2 90    2 90    2 90  -* @ !:-*  0''--@Times New Roman-*-*---@Times New Roman-*-*-@Times New Roman-*-*@Times New Roman-*-*--@Times New Roman-*-*- 2 Z00 RESULTS  ---  2 Zk0  -* @ !;[0-* - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 n00 GADA: - - -   2 nX0  - - @Times New Roman-*- *-  @Times New Roman-*- * 2 ni0  - - -   2 nl0  <  2 n0  -* @ !?oi-*  0'' -&-&-&  2 Q0   -#-#-#  2 b0   - - @Times New Roman-*- *- - - - --@Times New Roman-*-*-- - - --@Times New Roman-*-*-@Times New Roman-*-*@Times New Roman-*-*- - @Times New Roman-*- *-  @Times New Roman-*- *2 n0 IA   2 n0 - 2 n0 2A   2 n0 :  2 n0  = 2 n0 IAA: - - -   2 n/0  --@Times New Roman-*-*- @Times New Roman-*-* 2 n30  - - -   2 n60  J  2 n0  -* @ !Ao-*@Times New Roman-*-*-*- - "Arial-+- +- @Times New Roman-+-+@Times New Roman-,-+,-+*-* @ !Mo3-*  0''@Times New Roman-*-+*@Times New Roman-*-+*@Times New Roman-*-+* @Times New Roman-*-+*@Times New Roman-*-+*@Times New Roman-*-+*-&-&-&  2 Q0   -#-#-#  2 b0   - - @Times New Roman-*- *- - - - --@Times New Roman-*-*-- - - - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  2 n0 ZnT8A: - - -   2 n0  --@Times New Roman-*-*- @Times New Roman-*-* 2 n0  - - -   2 n0  7  2 n0  -* @ !:o-*  0'' -&-&-&  2 Q0   -#-#-#  2 b0   - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *- - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 n0 TGA:   2 n0    2 n0  B  2 n\0   2 n_0   2 nf0 Hyd21: - - -   2 n0  - - @Times New Roman-*- *-  @Times New Roman-*- * 2 n0  - - -   2 n0  ?  2 n0  -* @ !Io-*-* @ !Bo-*  0''- - @Times New Roman-*- *- - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  0.2 00 normal  ..Z 2 Z0 =..a2 a0  20.- - -   2 r0     2 /0   - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  2 -0 Version   2 Z0 8- - -   2 a0    - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  .2 0 normal  .. 2 0 =..2 0  5.- - -   2 0    - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  .2 0 normal  ..A 2 A0 =..H2 H0  0.010.- - -   2 j0    - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  .2 0 normal  .. 2 0 =..2 0  0.020.- - -   2 0    - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  .2 0 normal  ..! 2 !0 =..(2 (0  0.050.- - -   2 J0    - - @Times New Roman-*- *- @Times New Roman-*- *@Times New Roman-*- *- - @Times New Roman-*- *-  e.2 e0 normal  .. 2 0 =..2 0  0.150.- - -   2 0   - - @Times New Roman-*- *- --@Times New Roman-*-*-- - - - - - - - @Times New Roman-*- *-  @Times New Roman-*- *2 - 0 01/02/2025  2 m0   2 @0 Report   2 e0   2 g0 Date --@Times New Roman-*-*- @Times New Roman-*-* 2 0  - - -   2 0   2  0 _____________  2 0    2 0    0''--@Times New Roman-*-*-@Times New Roman-*-*@Times New Roman-*-* 2 8m0 This test was developed and its performance verified by the Autoantibody Laboratory at the Barbara Davis Cent  R2 //0 er. It has not been cleared or approved by the  @Times New Roman-*-*@Times New Roman-*-* 2 8}0 US Food and Drug Administration. Brief descriptions of the method and performance characteristics are available upon request.     2 }0   72 0 This laboratory is certified  @Times New Roman-*-*@Times New Roman-*-* 2 8}0 under the Clinical Laboratory Improvement Amendments (CLIA) and the College of American Pathologists (CAP) as qualified to pe    ,2 0 rform high complexity    @Times New Roman-*-*@Times New Roman-*-*--@Times New Roman-*-*- 52 ^0 clinical laboratory testing.---  2 0   -*-%9--*'-*-%1--*'-*-%1--*'-*-%0MM--*'-*-%0MM--*'- -   00//.. ՜.+,D՜.+, hp|  t   Diagnostic Autoantibody RequestCUniversity of 鶹ý School of Medicine, Anschutz Medical Campus<DIRECTIONS FOR SENDING SAMPLES FOR AUTOANTIBODY MEASUREMENTU Samples cannot be tested if extremely hemolyzed or lipimic. No frozen whole blooU (CPT 86337) o Complete Islet Autoantibody plus 21-Hydroxylase, Transglutaminase  AC B Requesting physician or clinic will be billed for this test. RESULTS Title Headings0fnzCreatedCreator LastSaved@BmMicrosoft Word 2016@ !"#$%&')*+,-./0123456789:;<=>@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F@][Data  1Table(-WordDocument?SummaryInformation(?2DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q