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���������-----t��������|4�(@Q(yyyy����'�'�'�'�'�'�'_*�-��'--�������'--yy��'� � � �.-y-y:&p� ��'� � :j%,�%y����@]綶������^�%
&&�'0(�%R�->F�-�%�--�%4��� ������'�'����(�������������������������������������������������������������������������-����������Y�: DIAGNOSTIC AUTOANTIBODY REQUEST
BARBARA DAVIS CENTER FOR CHILDHOOD DIABETES
University of 麻豆传媒高清 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 patient抯 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 (Addison抯 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.
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