EV MED Research Enterovirus VP1 Immunoperoxidase stain Test Request Form (Dr. Chia)
EV MED RESEARCH
25332 Narbonne Ave, Suite 170, Lomita, Ca. 90717
Tel: 310 534 9700 Fax: 310 534 9701
Patient Name: ________________________________________ DOB:_________________
Address: ___________________________________________________________________ City:_______________________________________ State:__________ Zip:___________ Phone: _______________________ Fax:_____________________
□ Male □ Female Email address: __________________________________________
Enterovirus VP1 Immunoperoxidase stain
CPT Code: 88342*
The qualitative immunoperoxidase is used to detect the presence of enteroviral protein within the stomach biopsies or other tissue sections.
Detects most of the human enteroviruses, including coxsackie A and B, echoviruses, and enteroviruses 68-71. The antibody used in this assay is specific for enteroviruses, but does not differentiate between serotypes
the service of a gastroenterologist is required to undergo an endoscopy and to obtain the biopsy tissue. 2-3 biopsies should be done on inflamed areas of the antrum, fixed in formalin and paraffin-embedded for pathological examination. Have the pathologist sent 5 unstained slides containing the paraffin-embedded tissue biopsy (4 micron thickness). The tissues should be on charged slides.
You can request the pathologist to send the slides including the pathology report to our address above.
You can send the requisition form and the payment separately to the address above.
1-2 week upon arrival
(The fee of this test does not include the endoscopy procedure.)
EV Med Research is a fee-for-service provider and does not bill any insurance carriers.
I agree to pay the costs for the analyses requested at the time of service. The receipt for the analyses will be sent to me from EV Med Research. If I choose, I can submit this receipt to my insurance carrier for reimbursement.
Patient Signature_____________________________________ Date ________________
* The CPT codes provided are based on EV MED’s interpretation of the American Medical Association’s Current Procedural Terminology (CPT) codes and are provided for informational purposes only. CPT coding is the sole responsibility of the billing party. Questions regarding coding should be addressed to your local Medicare carrier. EV MED assumes no responsibility for billing errors due to reliance on the CPT codes illustrated in this material.
Some of the immunohistochemical stain(s) used for evaluation of this specimen are analyte-specific reagents. These tests were developed and their performance characteristics were determined by EV Med Research Laboratory. They have not been cleared or approved by the Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. The test is used for clinical purposes. It should not be regarded as investigational or for research.
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