HLA Testing Service Request – Disease Association

HLA Disease Association Testing Order Form
Thank you for your interest in HLA testing services from Stanford Blood Center. Please complete the following order form, print a copy and send it with your sample(s) to:

Stanford Blood Center — HLA Lab
3373 Hillview Avenue
Palo Alto, CA 94304

Phone: (650) 724-6742 or (650) 723-5548, Option 0
FAX: (650) 723-6350
Email: secure-HLAsupport@lists.stanford.edu

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

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

Patient Information
Patient name:*

First NameMiddle NameLast Name
Medical record number:*
Patient date of birth:*

MonthDayYear
Date
Patient sex at birth:*

MaleFemalePatient prefers not to state
Ethnicity:

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 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:*
Please enter a valid phone number.
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
Specimen source:

Peripheral Blood (one yellow-top ACD tube required)
Test/specimen information: click here
Draw date:

MonthDayYear
Date
Draw time:
Phlebotomist initials:
Any Additional Comments or Considerations:
Please press "SUBMIT" then print the PDF in your confirmation email and send it with your samples to:

Stanford Blood Center — HLA Lab
3373 Hillview Avenue
Palo Alto, CA 94304

Phone: (650) 724-6742 or (650) 723-5548, Option 0
FAX: (650) 723-6350
Email: secure-HLAsupport@lists.stanford.edu

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