Oct/11/2017 41 :42 AM Quest Diagnostics 949-940-7637 r ...

r-.) Quest Oct/11/2017 9:41:42 AM

Quest Diagnostics 949-940-7637

Quest Diagnostics

_.; Diagnostics"'

Account#

Ordering

1/1

Date of Collection

Physician Name

Address

Patient Date of Birth I Patient ID #/Acc #

City, State, Zip

Phone

Patient Name (Last, First)

Fax

NPI

Select:

D MS Pt Program (Medicaid patients excluded)

D Medicaid ID # and State:

Please check one ICD Code

(Required)

o Multiple Sclerosis (G35)

o Crohn's Disease (K5090)

o Other

(Please write applicable description and code)

Patient Sex

D Male D Female

TEST

91665(X) D STRATIFY JC~ Antibody ELISA (with Index) w/Reflex to Inhibition Assay

Offered for multiple sclerosis patients only.

The JC Virus (JCV) is associated with progressive multifocal leukoencephalopathy (PML). Detection of antibodies to JCV in serum or plasma is a reliable indicator of exposure to JCV. The analytical performance characteristics were determined for multiple sclerosis patients.

Do Not use this Form to order any other tests; use a separate requisition.

Visit to: ?Schedule an appointment (or call 888?277-8772) ?Find Quest Diagnostics locations (or call 800-377?8448)

Walk-in patients are always welcome

Ouest. O~Gst uicgnostts. 1119 associate ................
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