HLA Testing Service Request

Ordering Physician / Laboratory
SBC bills the physician/physician's facility. SBC does not bill patients or patients' insurance providers.
Requesting entity:*
Ordering physician:*

First NameLast Name
Requesting entity billing address:*

Street Address

Street Address Line 2

CityState

Zip Code
Department:
ICD-10
ICD-10 diagnostic insurance codes NOT required for Kaiser patients; suggested for all other patients.
NPI/UPIN:*
Ordering physician phone:*
Ordering physician FAX:
Please enter a valid FAX number. If reports are to be sent by FAX, please provide this number here.
Ordering physician email:*
Reports will be sent as attachments via secure email or FAX. Contact HLAsupport@lists.stanford.edu for help.

Specimen Information
STANFORD SPECIMENS:
Send to clinical lab for transport.
Non-STAT samples must be received by 1:00 p.m. on Fridays.

NON-STANFORD SPECIMENS
Send via courier (FedEx, UPS, etc.)

Test/specimen information: click here
Peripheral BloodBone MarrowPre-Extracted DNABuccal SwabOther
Yellow Top (ACD) — Required for Typing, Chimerism and CrossmatchRed Top (No Anti-Coagulant) — Required for Antibody, DSA and CrossmatchOther
Collection date:

MonthDayYear
Date
Collection time:
Phlebotomist / clinician initials:
Phlebotomist / clinician instructions:
- Complete date and time of collection, and initial.
- DO NOT REFRIGERATE or FREEZE SAMPLES.
- DO NOT SPIN SAMPLES.
- Blood samples should be maintained as whole blood and room temp.
- Samples must be labeled with patient’s full name, DOB, collection date and time.
- Unlabeled samples will be rejected.
- Press SUBMIT.
- You will receive a confirmation email with a copy of your responses.
- PRINT AND RETURN THE REQUISITION COPY WITH THE SAMPLE.
Should be Empty:

HLA Transplant Testing Order Form