EFTA00304938.pdf

I III II iii 3233025- )!RUCE MOSKOWITZ, ND NATIONWIDE ACCOUNT 1411 N RADLER DR STE 7100 WEST PALO DEACH, EL 33401-itill nm" (56624S ME COLLECTED I I BELLI*: C My Account o Insurenos Provided i Lab Catd/Ssui ( Priem nod. PAS salt PAPAL Waal. Pavel. ;._? sit\ n GtSTRA N • IF APPlICABLE) Patient Service Center location and appointmen scheduling information is on the back. Each sample should be labeled with at least two patient identifiers at time of collection. ICD Diagnosis Codes are Mandatory. Fill in the applicable fields below. nia Ij AM TOTAL Yam% OPM pAL I Faettog _ HR D Non Fasting PIARIN ORDERING/SUPERVISING PHYSICIAN ANO/OR PAYORS ) 1376970335 ACCETTUR0.000800 Ser 1306702076 HOSKOMIT2,0RUCE ( i 1477952133 HOWICHENS,PRITTAN (MUST BE INDICATED) ( CCB CICHE ( DOS Z+DLUECRD i HUSK AETNA I ADCITL PLAYS.: Dr. DINS to Mgt viols ADDRESS. twits CITY PANEL CON STATE NENTS ON BACK ORGAN / DISEASE PANELS 34352 7_, Electra Ins Panel MICOMEllaesuc isaction Panel 10155L20mskbr.uprorrusi tenIEComp Metabolic had S 87.00DUpid Panel IFaStlagt 14152 Dip I d Pa n al wfibillex DADL S DE212100 Obstetric hell valleigi V.1.5 'DIEGOEDICipstitis arab* vallellar 5 1/314 Renal Fungal Panel S EISIORHomaglogn I. •3309 Hematocm L etraOcec (HO. MCI. MC, MSC. PIT) L on.HCBC vot•fl figi. Hit litttWOC,FitOR) I. 88847 PI vain IPIR B PTT. Activated B 7788 DABO Grouts & Rs Type y (4237 K AEPTumor Market S zzy Miming S 234 Alkaline ProsphAase $ it23 0 aer $ 243 0 Amyrne $ 249 O anarneniarn weroatter Nam $ 7.6 c Antibody Sc., ROC A/RAW t V 072 CAST $ 225 C011ilybol. WOO 3 117 DBiSrutin.Tosal s COI TIONAl IDIS (INCLUDE C0/.0ETED.ST /Oat Mi0 ORDER CODE) Mlles tests are patterned S S *2903 *39356 *303 11173 897$ 8334 374 375 402 00243 4021 @el 466 470 8482 8477 19833 8444 Bpi 0435 SIM BIN 616892 439 491 6472 _ 891431 31789 ®1507 C ZIP 61571 593 599 C-Reactive Protein KAP) CA 2729 CA 126 Calcium CCP Ms ig.1 CEA Onolestaiol. Total CC Total Croatians DMA Sulfate. Immunoassay 1.01. ChaleaterO1. Dract Estragol Marion Folic Abd ESN GGT Dame Gisialx:a Sow 9491 OS oat GY Gum Emaiivai Myer TOot LOtes• CY Glucose. Plasma GY Glucose. Serum BCC. Sarum. Ousl 5 100, Serum. Guam Nomoplogn Mc Hemoglobin AlP meAG Hap B Surface Ab Oval Nev B Surface Ag wflelle: Conform Map CArlottatty aelitelex to Gape S i4M112 AGAB. 4th smflx S Homorystemt ns CRP mum mmureflxiiiim OFEL 07573 bonnet.% sr, s B866 ,,_ T4 iThyrounel. Rae s • Additional Marge Rae ID and Sesamilbll ABN required for tests with these symbols S S $ S S PATIENT EMAIL ADDRESS WNW 0 • / Cell PH 1( ) J. 'l OF INSUREDTES•131.38if ',VEY ALST.F331.6000 ODES TWA We. NT STREET ADDAESS ICR CSuKEORESPONSIBLE PARTY) APT I KEY* RELATIONSKIPTO INSURED: PRMARY INSURANCE CO. NAME MEMBER! INSURED ID NO. • Medicare Limited Coverage Tens a SELF C SPOUSE 0 DEPENDENT GROU • a- May rot become] for the reported magncsis. F =Hes panted frequency rules tot CO:MCA & • A test or service perforeed weiresearchtexcerrental kit B = Has DILL thongs nib fisionvelatad retovese linsiatert Iron LOH Lead. Wood S S TN 615 U LH $ 606 0 ow. s 6648 Lrit emus aa amen a goose. le* S '.4672 Magnesium $ 6517 lifirnabutrat. Rargam (Asia merest Fecal Globe% Faces . FIT InSarST4 1t200❑ Diagnostic F MEI Macicare Scram Provide signed ABN who aaraintai 6449 0 UA. OtPladt 0 7903 0 UA Diana witelle: Mlgoscogc 54130 ua. Compraelp*eha Micemeora 030290 UA. Complete, yeReaex Cuturti 314 0 Wee Nitrogen MUNI 9050 uric AgE 916 K woo* Acid 4439 K Varkteaa-ZOStet VirusAt. IMG) 7015 0 Manse 1112figic Add 927 O %%min B12 817306 0 Van*, 0.75.410acy.latOrrograma 891935 K Moran GeOurageanCL` kriging MICROBIOLOGY 4 Saga IlismisEl Curture, Aerobic Berne.' Carture.Inaram a Amerob.c• caure, group A sver Culture: Group B Stvp• Culture. Genoa Cuhure.Tnroat• OA" Urns. liouga•Onc roses earn tied lipealeneeTYP• Cftniead O Inemnital • Uglaral U Lave ANAT Stool PrnI10610s• issysnocamm 101058 Ultra. Stool Shim toxins voRall H pylon Ag. EIA Stool 148390 Pi pylori Urea 8reatkTest Ell LI 0 40Pwiromainent Stain 4500 4446 44$ 5617 45N 394 PM' )0307978 CP 307978 t ( )e 688 Rit CNOLESTECOl j(p35-Caiawm 2(4 hr. Lime- :OMME/175,CUNICM INFORMATON:1Otelliat in& Midas Slgra6lreiNqulrSSld PA NY, Nib VM Many payers (Including Medicate sad Medicaid) have medical necessity requirements. You should Daly order those tests which are medically necessary for the diagnosis and treatmen of the patient. 718'Phosphorus 133 ;Potassium 745 ,.,Progsterone 746 Acitactin 85363 —I•SA.TOMI 793 _Ratictilocni Count. Automated 4418 Rheumatoid radar RPR iMondaringl mllellex Titer 636126 RpR tr0CI peRallea Consren KS — Rubel* IgG Sad Rate by MMINest 16913 Teatosnrons,Total. LCMSSAS 873 _ wove/one. TOM. mo• 5081 Tbrad Pemoidaieamecclies IMO/ 836127 T nrTsigH:ce sgelnox ik" TI, Free 1029 73. Fns 869 111 Tete 6861 " T3 8857 m anytounel, tool *290 8896 8899 S S $ S S S S SR SR $ $ S S S Men additional charge. Owe Gs. Manta Iv neaNisp.)14 essinol 0naula r..• larglerges Wen. I 2•00•11•60 'Anna to want 41400/0.6.14100. ••••Cainette 31/¢/Ac Lia t CO 441& C‘0nt RULGTFLAS a lag PCS0C NFIL( TOTAL TESTS ORDERED 78300020 76100020 78300020 3233025 3233025 NAME: __ _____ 22300020 323302S 123302S 70300020 3233025 EFTA00304938