PO Box 5045Sioux Falls SD 57117-5045605.322.7187 or 800.560.4846Fax: 605.322.7183

Pathologist Smear Review - Request FormTest Requested:

Blood smear, peripheral by pathologist, with written report (CPT 85060) [Test ID: 486 Mnemonic: PATHREV] Tzanck smear; Special stain, inclusion bodies (CPT 87207) [Test ID: 95 Mnemonic: TZANCK]

Patient Demographics & Collection Information:

Patient Service Location (mark one): Hospital Inpatient Hospital Outpatient Clinic/Physician OfficeSpecimen Collection Date: ______________ Time: _________ Patient Name: ______________________________________________________________________________

Last Name First Name MIAge/DOB: ____________________________ Sex: M / F Specimen ID#: _________________________Ordering Facility: ____________________________________________________________________________Ordering Physician: _______ _____ Telephone: ____________________________ Last Name First Name

Patient Clinical Information:ICD-Diagnosis Code(s) (reason for test request): (1)_______________ (2) ________________ (3)______________Diagnosis/reason for review: ____________________________________________________________________________________________________________________________________________________________________

Attach copy of hemogram or CBC results

Laboratory Use Only:____ Inpatient (IH)____ Outpatient (OH)

85060 Blood smear, peripheral, by pathologist, written report 87207 Special stain, inclusion bodies (Tzanck) Other: (describe)

Pathologist Date

Form Path Review of Peripheral Smear AMRL 066F1 (Version 1.1) Forms, Forms Approved and current Effective starting 6/22/2016

Blank copy 3031889. Last reviewed on 2/19/2018. Printed on 9/25/2019 12:29 (CDT). Page 1 of 1