Physician
Fax Order Form
SOUTH BEND
MEDICAL
FOUNDATION
Ordering Physician
Physician
530 N. Lafayette Blvd. ● South Bend, IN 46601
(574)234-4176 ● (800)544-0925
DR#
Client Code
www.sbmf.org
Follow Steps 1-4 for a complete order. Fax orders to 574-807-3010 or 1-866-674-5138
Step 2. Frequency
Step 1. Demographics
One time draw: date (if needed)
Patient Name
Last
DOB
First
Standing order (Note: Standing orders are valid for one year.)
SS#
Step 3. Mark Tests Needed
Panel Tests
Step 4. List Diagnosis (DX) or ICD-9 Code For Each Test
DX
Individual Tests
DX
Individual Tests
DX
28192
Acute Hepatitis Panel
29241
Cholesterol, Total
29152
SGPT (ALT)
23058
Electrolyte Panel
29131
Creatinine
29028
Sodium
35205
General Health Panel
31042
Digoxin
30016
T3, Free
29525
Hepatic Function Panel
30055
Ferritin
30113
T4, Free
29048
Lipid Panel
29129
Glucose
30213
T4, Total
29526
Metabolic Basic Panel
30089
HCG, Qualitative
30017
TSH
29527
Metabolic
Comprehensive Panel
23409
Hemoglobin A1C
25074
UA w/Micro. C&S if ind
35839
OB Panel w/Syphilis Scrn
by Immunoassay
28270
HIV-1/2 Ab Screen
25075
Urinalysis
w/Microscopic
35842
OB Panel w/Syphilis Scrn
by RPR
29100
Iron includes (TIBC)
21054
Urine C&S, clean catch
(sens if ind)
29528
Renal Function Panel
23084
Magnesium
31032
Valproic Acid
(Depakote)
29168
Phosphorus
29127
Potassium
23119
Protein, Total
25045
Prothrombin Time (PT)
30178
PSA, diagnostic
30078
PSA, screening
25230
Sed Rate
29255
SGOT (AST)
Individual Tests
29109
Amylase
29021
BUN
30225
Ca 125
29039
Calcium
25517
CBC with Diff
25014
CBC without Diff
30181
CEA
DX
Additional Tests
DX
Optional
Stat
Phone
Fax
Copy to
Special Instructions:
Fasting?
Faxed by
Date/Time
090607-1 (1-13)
Individual Tests Included in Panels
Panel
Test
Acute Hepatitis
Panel
Order
#
Electrolyte Panel
23058
28192
Hepatic Function
Panel
29525
Lipid Panel
29048
Metabolic Basic
Panel (BMP)
29526
Metabolic Panel
Comprehensive
(CMP)
29527
Renal Function
Panel
29528
General Health
Panel
35205
Obstetric Panel
35839
Hepatitis A IgM Antibody
Hepatitis B Core IgM Antibody
Carbon Dioxide
Chloride
Potassium
Albumin
Alkaline Phosphatase
ALT (SGPT)
AST (SGOT)
Cholesterol, Total
Triglycerides
HDL Cholesterol
Calcium
Carbon Dioxide
Chloride
Creatine
Glucose
Albumin
Alkaline Phosphatase
Bilirubin, Total
Calcium
Carbon Dioxide
Chloride
Creatine
Glucose
Potassium
Albumin
Calcium
Carbon Dioxide
Chloride
Creatinine
Glucose
Albumin
Alkaline Phosphatase
ALT
AST
Bilirubin, Total
Calcium
Carbon Dioxide
Chloride
Creatinine
Glucose
ABO Blood Group and Rh Type
CBC with Automated Differential
HDN RBC Antibody Screen
Individual Tests
Included
Hepatitis B Surface Antigen w/ Confirmation if indicated
Hepatitis C Antibody
Sodium
Anion Gap (calculated)
Bilirubin, Direct and Total
Protein, Total
Albumin/Globulin Ratio (calculated)
Globulin (calculated)
LDL Cholesterol (calculated)
Total Cholesterol/HDL Ratio (calculated)
Non-HDL Cholesterol (calculated)
Potassium
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
Protein, Total
SGOT (AST)
SGPT (ALT)
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
Globulin (calculated)
Albumin/Globulin Ratio (calculated
Phosphorus
Potassium
Sodium
Urea Nitrogen (BUN)
Anion Gap (calculated)
Estimated Glomerular Filtration Rate (eGFR) (calculated)
Potassium
Protein, Total
CBC with Diff
Sodium
TSH
Urea Nitrogen (BUN)
A/G Ratio (calc)
Anion Gap (calc)
Globulin (calc)
Hepatitis B Virus Surface Antigen, with CNFRM. if IND.
Rubella IgG Antibody
Treponema pallidum Total Antibodies, by CLIA
090607-1 (1-13)