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Microbiology Test Request*

Client Information (required) Patient Information (required)

Client Name Patient ID (Medical Record No.)

Client Account No. Patient Name (Last, First, Middle)

Client Phone Client Order No. Sex Birth Date (mm-dd-yyyy)

Male Female
Street Address Collection Date (mm-dd-yyyy) Time am
pm
City State ZIP Code Street Address

City State ZIP Code

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Submitting/Referring Provider Name (Last, First)
Phone

Fill in only if Call Back is required.

Phone (with area code) Fax** (with area code) Reportable Disease Information
Complete information as indicated by your state requirements.
Client Name
National Provider Identification (NPI)
Client Account No.
**Fax number given must be from a fax machine that complies with applicable
HIPAA regulation.
Client Phone Client Order No.
Reason for Testing (required)
___________________________________________________ Patient Street Address
___________________________________________________
___________________________________________________ City State ZIP Code

ICD-10 Diagnosis Code County Race/Ethnicity

Phone Specimen Type

Note: It is the client’s responsibility to maintain documentation of the order.
New York State Patients: Informed Consent for Genetic Testing Venous Capillary
Parent/Guardian Name (Last, First)
“I hereby confirm that informed consent has been signed by an
individual legally authorized to do so and is on file with this office
or the individual’s provider’s office.”
Signature
*For a list of serology testing for infectious diseases, see Infectious Disease Serology
Test Request (MC0767-29).
Note: It is the client’s responsibility to maintain documentation of the order.

Ship specimens to: Billing Information

Mayo Clinic Laboratories • An itemized invoice will be sent each month.
3050 Superior Drive NW • Payment terms are net 30 days.
Rochester, MN 55901
Call the Business Office with billing-related questions:
Customer Service: 800-533-1710 800-447-6424 (US and Canada)
507-266-5490 (outside the US)

Visit www.MayoClinicLabs.com for the most up-to-date test and shipping information, or scan the code to learn more.
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©2022 Mayo Foundation for Medical Education and Research Page 1 of 4 MC0767rev1222
Patient Information (required)
Patient ID (Medical Record No.) Client Account No.

Patient Name (Last, First, Middle) Client Order No.

Birth Date (mm-dd-yyyy)

MOLECULAR DIAGNOSTICS  EPCRB Ehrlichia/Anaplasma, Molecular Detection,  MTBXP Mycobacterium tuberculosis, Complex,
PCR, Blood Molecular Detection, PCR, Sputum
 LCADP Adenovirus, Molecular Detection, PCR,
Plasma  ENTP Enterovirus, Molecular Detection, PCR,  MTBRP Mycobacterium tuberculosis Complex,
Plasma Molecular Detection, PCR, Varies
 LADV Adenovirus, Molecular Detection, PCR,
Varies  LENT Enterovirus, Molecular Detection, PCR,  AMGEN Mycoplasma genitalium, Transcription-
Varies Mediated Amplification, Varies
 BABPB Babesia species, Molecular Detection,
PCR, Blood  EBVPV Epstein-Barr Virus (EBV),  MPRP Mycoplasmoides pneumoniae,
Molecular Detection, PCR, Varies Molecular Detection, PCR, Varies
 BTWGS Bacterial Typing, Whole Genome
Sequencing, Varies   EBVQN Epstein-Barr Virus DNA Detection  PARVP Parvovirus B19, Molecular Detection,
and Quantification, Plasma PCR, Plasma
 BARTB Bartonella, Molecular Detection, PCR, Blood
 GIP Gastrointestinal Pathogen Panel, PCR, Feces  PARVO Parvovirus B19, Molecular Detection,
 BARRP Bartonella, Molecular Detection, PCR, Varies PCR, Varies
 GNRG Gram-Negative Bacillus Antimicrobial
 PBKQN BK Virus DNA Detection and Quantification, Resistance Genes, PCR Panel, Varies  PNRP Pneumocystis jiroveci, Molecular Detection,
Plasma PCR, Varies
 HEVQU Hepatitis E Virus RNA Detection and
 UBKQN BK Virus DNA Detection and Quantification, Quantification, Real-Time RT-PCR, Serum  POWVB Powassan Virus, RNA, Molecular Detection,
Random, Urine PCR, Blood
 HSVPB Herpes Simplex Virus (HSV),
 BPRPV Bordetella pertussis and Bordetella Molecular Detection, PCR, Blood  POWVU Powassan Virus, RNA, Molecular Detection,
parapertussis, Molecular Detection, PCR, Random, Urine
PCR, Varies  HSVC Herpes Simplex Virus (HSV),
Molecular Detection, PCR, Spinal Fluid  POWVS Powassan Virus, RNA, Molecular Detection,
 BMIPB Borrelia miyamotoi Detection PCR, Blood PCR, Serum
 HSVPV Herpes Simplex Virus (HSV),
 BMIYC Borrelia miyamotoi Detection PCR, Molecular Detection, PCR, Varies  POWVC Powassan Virus, RNA, Molecular Detection,
Spinal Fluid PCR, Spinal Fluid
  HBRP Histoplasma capsulatum/Blastomyces
 BRBPS Broad Range Bacterial PCR and species, Molecular Detection, PCR, Varies  RP Respiratory Panel, PCR, Nasopharyngeal
Sequencing, Varies
 HHV6 Human Herpesvirus-6, Molecular  RPB Respiratory Panel, PCR, Varies
 CAURS Candida auris Surveillance, Detection, PCR, Plasma
Molecular Detection, PCR, Varies  STFRP Shiga Toxin, Molecular Detection, PCR,
 HHV6V Human Herpesvirus-6, Molecular Feces
 CAURB Candida auris, Molecular Detection, PCR, Detection, PCR, Spinal Fluid
Blood  TIKLB Tick-Borne Panel, Molecular Detection,
 FLUNP Influenza Virus Type A and Type B, and PCR, Blood
 CAURP Candida auris, Molecular Detection, PCR, Respiratory Syncytial Virus (RSV), Molecular
Random, Urine  TOXB Toxoplasma gondii, Molecular Detection,
Detection, PCR, Nasopharyngeal Swab
PCR, Blood
 CHIKS Chikungunya Virus, PCR,  FLUMS Influenza Virus Type A and Type B,
Molecular Detection, Serum  PTOX Toxoplasma gondii, Molecular Detection,
and Respiratory Syncytial Virus (RSV),
PCR, Varies
 CHIKC Chikungunya Virus, PCR, Molecular Detection, PCR, Varies
Molecular Detection, Spinal Fluid  WHIPB Tropheryma whipplei, Molecular Detection,
 JCPCR JC Virus, Molecular Detection, PCR,
PCR, Blood
 CDPCR Clostridioides difficile Toxin, PCR, Feces Spinal Fluid
  URRP Ureaplasma species, Molecular Detection,
 CIMRP Coccidioides immitis/posadasii,  KKRP Kingella kingae, Molecular Detection, PCR,
PCR, Varies
Molecular Detection, PCR, Varies Varies
 VRERP Vancomycin-Resistant Enterococcus,
 CBBRP Coxiella burnetii (Q Fever),  KPNDP Klebsiella pneumoniae Carbapenemase
Molecular Detection, PCR, Varies
Molecular Detection, PCR, Blood (blaKPC) and New Delhi Metallo-beta-
Lactamase (blaNDM) Surveillance, PCR,  VZVPV Varicella-Zoster Virus, Molecular
 CBSRP Coxiella burnetii (Q Fever), Detection, PCR, Varies
Varies
Molecular Detection, PCR, Serum
 LEGRP Legionella species, Molecular Detection,  WNVBL West Nile Virus, RNA, PCR,
 CBRP Coxiella burnetii (Q fever), Molecular Detection, Blood
PCR, Varies
Molecular Detection, PCR, Varies
 PBORB Lyme Disease, Molecular Detection, PCR,  WNCSF West Nile Virus, RNA, PCR,
 CMVQN Cytomegalovirus (CMV) DNA Detection and Blood Molecular Detection, Spinal Fluid
Quantification by Real-Time PCR, Plasma
 LYMPV Lyme Disease, Molecular Detection, PCR,  WNVUR West Nile Virus, RNA, PCR,
 CMVNG Cytomegalovirus (CMV) Drug Resistance, Varies Molecular Detection, Random, Urine
Next-Generation Sequencing, Plasma
 LCMAL Malaria, Molecular Detection, PCR, Varies  WNVS West Nile Virus, RNA, PCR,
 CMVPV Cytomegalovirus (CMV), Molecular Detection, Serum
Molecular Detection, PCR, Varies   CSFME Meningitis/Encephalitis Pathogen Panel,
PCR, Spinal Fluid  WNCSF West Nile Virus, RNA, PCR,
 DENGS Dengue Virus, Molecular Detection, PCR, Molecular Detection, Spinal Fluid
Serum  MHRP Metamycoplasma hominis,
Molecular Detection, PCR, Varies  RZIKU Zika Virus, PCR, Molecular Detection,
 DENGC Dengue Virus, Molecular Detection, PCR, Random, Urine
Spinal Fluid  LCMSP Microsporidia species, Molecular Detection,
PCR, Varies  RZIKS Zika Virus, PCR, Molecular Detection, Serum

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Patient Information (required)
Patient ID (Medical Record No.)
Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy)
VIRAL HEPATITIS AND HIV
MOLECULAR TESTING
Hepatitis B Virus
 HBVQN Hepatitis B Virus (HBV) DNA Detection and
Quantification by Real-Time PCR, Serum
Hepatitis C Virus
 HCVQN Hepatitis C Virus (HCV) RNA Detection
and Quantification by Real-Time Reverse
Transcription-PCR (RT-PCR), Serum
 HCVRP HCV RNA Detect/Quant Prenatal, S
 HCVQG Hepatitis C Virus (HCV) RNA Quantification
with Reflex to HCV Genotype, Serum
Hepatitis C Virus Genotype, Serum
 HCVG
Hepatitis C Virus Genotypic Antiviral Drug
 HCVDR
Resistance, Serum
Human Immunodeficiency Virus
 HIVQN HIV-1 RNA Detection and Quantification,
Plasma
 HIQNP HIV-1 RNA Detection and Quantification,
Prenatal, Plasma
 HIQDR HIV-1 RNA Quantification with Reflex to
Genotypic Drug Resistance to Reverse
Transcriptase, Protease, and Integrase
Inhibitors, Plasma
 HIVDR HIV-1 Genotypic Drug Resistance
to Reverse Transcriptase, Protease,
and Integrase Inhibitors, Plasma
Hepatitis E Virus
 HEVQU Hepatitis E Virus RNA Detection and
Quantification, Real-Time RT-PCR, Serum
 HEVG Hepatitis E Virus IgG Antibody, Serum
 HEVM Hepatitis E Virus IgM Antibody Screen
with Reflex to Confirmation, Serum
 HEVML Hepatitis E Virus IgM Antibody
Confirmation, Serum
SPECIMEN CULTURES (RAW SPECIMEN)
Bacterial Cultures
Bacterial Culture, Anaerobic with
 ANAES
Antimicrobial Susceptibilities, Varies
 CFRCS Bacterial Culture, Cystic Fibrosis with
Antimicrobial Susceptibilities, Varies
 LEGI Legionella Culture, Varies
 HELIS Helicobacter pylori Culture with
Antimicrobial Susceptibilities, Varies
Client Account No.
Client Order No.
Fungal Cultures ANTIMICROBIAL SUSCEPTIBILITY
 FBL Fungal Culture, Blood Identification of organism submitted:
 FDERM Fungal Culture, Dermal  MMLRG Antimicrobial Susceptibility,
Acid-Fast Bacilli, Rapidly Growing, Varies
 FGEN Fungal Culture, Routine
 MMLSG Antimicrobial Susceptibility,
 FVAG Fungal Culture, Vaginal
Acid-Fast Bacilli, Slowly Growing, Varies
 FS Fungal Smear, Varies
 ZMMLS Antimicrobial Susceptibility,
Mycobacterial Cultures Aerobic Bacteria, MIC, Varies
 SAFB Acid-Fast Smear for Mycobacterium, Varies  MMLSA Antimicrobial Susceptibility,
Anaerobic Bacteria, MIC, Varies
 TBIDS Culture Referred for Identification,
Mycobacterium and Nocardia with  TB1LN Antimicrobial Susceptibility,
Antimicrobial Susceptibility Testing, Varies Mycobacterium tuberculosis Complex,
First Line, Varies
 CTB Mycobacteria and Nocardia Culture, Varies
 MMLNS Antimicrobial Susceptibility,
 CTBBL Mycobacterial Culture, Blood Nocardia species and other
Viral Cultures Aerobic Actinomycetes, Varies
  VIRNR Viral Culture, Non-Respiratory, Varies  MMLYP Antimicrobial Susceptibility Panel, Yeast,
Varies
ISOLATED ORGANISM REFERRED  CARNP Carbapenemase Detection-Carba NP Test,
FOR IDENTIFICATION Varies
All of the following information must be submitted  KPNRP KPC (blaKPC) and NDM (blaNDM)
to obtain identification of any organism submitted. in Gram-Negative Bacilli,
Molecular Detection, PCR, Varies
Transport Medium
 MTBPZ Mycobacterium tuberculosis Complex,
Pyrazinamide Resistance by
Recovery Medium pncA DNA Sequencing, Varies
 OXVRP Oxacillin-Hydrolyzing Beta-Lactamase
(blaOXA-48-like) and Verona Integron-
Extent of Identification Encoded Metallo-Beta-Lactamase
(blaVIM) in Gram-Negative Bacilli,
Molecular Detection, PCR, Varies
Date Collected (mm-dd-yyyy)
 OVSRP Oxacillin-Hydrolyzing Beta-Lactamase
(blaOXA-48-like) and Verona Integron-
Encoded Metallo-Beta-Lactamase
Suspect Brucella, Fancisella, Burkholderia pseudomallei,
Bacillus anthracis, Yersinia pestis?   Yes  No (blaVIM) DNA Surveillance, PCR, Varies
 TBNGS Mycobacterium tuberculosis Complex,
Description (Gram reaction, Morphology, tests performed)
Molecular Detection of Drug Resistance
_________________________________ Markers, Whole Genome Sequencing,
_________________________________ Varies
_________________________________  TBPZA Susceptibility, Mycobacterium tuberculosis
Complex, Pyrazinamide, Varies
  VRERP Vancomycin-Resistant Enterococcus,
 FUNID Culture Referred for Identification, Fungus
Molecular Detection, PCR, Varies
 CTBID Culture Referred for Identification,
Mycobacterium and Nocardia, Varies
 TBIDS Culture Referred for Identification,
Mycobacterium and Nocardia with
Antimicrobial Susceptibility Testing, Varies
 IDENT Organism Referred for Identification,
Aerobic Bacteria
 ANIDE Organism Referred for Identification,
Anearobic Bacteria
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Patient Information (required)
Patient ID (Medical Record No.)
Patient Name (Last, First, Middle)
Birth Date (mm-dd-yyyy)
DIRECT AND SPECIAL EXAMINATION
 SFUNG 1,3-Beta-D-Glucan (Fungitell), Serum
 ACARP Acanthamoeba species,
Molecular Detection, PCR, Ocular
 ESBLS Extended-Spectrum Beta-Lactamase-
Producing Gram-Negative Bacteria
Surveillance Culture, Feces
 FLARP Free-Living Amebae, Molecular Detection,
PCR, Varies
 ALGAL Galactose-Alpha-1,3-Galactose
(Alpha-Gal), IgE, Serum
 APGAL Galactose-Alpha-1,3-Galactose
(Alpha-Gal) Mammalian Meat Allergy
Profile, Serum
 GSBV Gram Stain for Bacterial Vaginosis, Varies
 HPFRP Helicobacter pylori with
Clarithromycin Resistance Prediction,
Molecular Detection, PCR, Feces
 UBT Helicobacter pylori Breath Test
 SHPV Human Papillomavirus (HPV)
DNA Detection with Genotyping,
High-Risk Types by PCR, SurePath, Varies
 HPV Human Papillomavirus (HPV)
DNA Detection with Genotyping,
High-Risk Types by PCR, ThinPrep, Varies
 LAGU Legionella Antigen, Random, Urine
 SSF1 Nocardia Stain, Varies
 SPN Pneumocystis Smear, Varies
 QFT4 QuantiFERON-TB Gold Plus, Blood
 ROTA Rotavirus Antigen, Feces
CHLAMYDIA TRACHOMATIS,
NEISSERIA GONORRHOEAE,
AND TRICHOMONAS VAGINALIS
 CGRNA Chlamydia trachomatis and Neisseria
gonorrhoeae, Nucleic Acid Amplification,
Varies
 CTRNA Chlamydia trachomatis, Nucleic Acid
Amplification, Varies
 GCRNA Neisseria gonorrhoeae, Nucleic Acid
Amplification, Varies
 MGRNA Neisseria gonorrhoeae, Miscellaneous
Sites, Nucleic Acid Amplification, Varies
 MCRNA Chlamydia trachomatis, Miscellaneous
Sites, Nucleic Acid Amplification, Varies
 MCTGC Chlamydia trachomatis and
Neisseria gonorrhoeae, Miscellaneous
sites, Nucleic Acid Amplification, Varies
 TVRNA Trichomonas vaginalis, Nucleic Acid
Amplification, Varies
 MTRNA Trichomonas vaginalis, Nucleic Acid
Amplification, Varies
Client Account No.
Client Order No.
PARASITOLOGY
 CRYPS Cryptosporidium Antigen, Feces
 CYCL Cyclospora Stain, Feces
 LEU Fecal Leukocytes, Feces
 FIL Filaria, Blood
 GIAR Giardia Antigen, Feces
 LMALP Malaria PCR with Parasitemia Reflex, Varies
 MTBS Microsporidia Stain, Varies
 OAP Ova and Parasite, Concentrate and
Permanent Smear, Microscopy, Feces
 PINW Pinworm Exam, Perianal
  MAL Rapid Malaria/Babesia Smear, Varies
ADDITIONAL TESTS
(INDICATE TEST NUMBER AND NAME)
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