EFTA00304939.pdf

rt Quest Diaonnstl II 78300020 - 6 I III 3233025 -1111111 , BRUCE HOSKOUITZ, ?ID NATIONWIDE ACCOUNT ' 1411 N FLAGLER DR STE 7100 lif ti siATt MIST PALM KAM FL 33401- 3410 'F Pia( ' 56115265 TE COLLECTED I I ens me. o MY Account 0 Insurance Provided o Lob CerdSelect CI Patient REGISTRA 1P N a OF APPLICABLE ▪ P YEAR S V5 / 2C h l i r5r3 Patient Service Center location and appointment scheduling information is on the back. Each sample should be labeled with at least two patient identifiers at time of collection. PATIENT EMAIL ADDRESS (PARENT ID e I MR ICD Diagnosis Codes are Mandatory. Fill in the applicable fields below. TIME ❑AM TOTAL Yaws . . Fasting : O PM MI. HA I Non Fasting %Lim ORDERING/SUPERVISING PHYSICIAN ANO/ORPAYORS (MUST BE INDICATED) ) 1376970335 ACCETRIRTI,ATIMA be 1386702876 tIOSHOUIT2,DRUCE ( 1477952133 H0UTCHEHS,BRITTAH ) CO CIGNA ) BCBS Z+BLUECRU ( i HUSK AETNA ADDITL PHYS.: Dr. VN.PHYSICLIN NAME PROVIDER Fax Results • Cleat I State ADDRESS: son to CITY 'ANEL COMPONENTS ON BACK NNA)PIN I I I I CELL MONS I Ranters PHONE ) IN' 'WA OF INSOREDIESPONSIBLE PARTY LASI, F557 LID(E/ WHO THAN FATIEN eelHST SIRS ET ADDRESS (00, IN SURE PRE SPONSIBLE PARTY) APT e KEY • STATE ZIP RELATIONSHIP TO INSURED C SELF O SPOUSE C DEPENDENT PRIMARY INSURANCE CO. NAME MEMBER INSURED ID NO. s GROUP • INSURANCE ADDRESS STATE ABN required for tests with these symbols Medicare Stu May not be coveted tor the repotted dagnosi Limited F = Has prescribed frequency rules for coverage Coring* & • A lest or senxo performed with teSealChierpoi mental kll Tests B related ccveraoe limitations Visit Clonal' r M cars sr Provide signed ABN who nommen old in STATE 21P ORGAN / aISEASE PANELS 34392 ,Ilyclrolyle Panel 10256Latent Function Panel 10165 [ —Sabo Metabolic Panel 10231r 'Comp Metabolic Panel 87800 r lipid Panellfa LI .11 C 14052 lipid Panel w/Rellee DiLDI. - 20210 Obstetric Panel lecterns,/ 10306 L tepees Panel. Acne a/Reflex 10314 nPenal furictonel Panel HEMATOLOGY 4I 1 _j uemeg rot @MD Hematocro 01759 CBC (Hob. Rat. ROC. L'aBC 06339 CBC w0410.0.lact MC, ll13C. Pit De 89947 APT wen INR 9763 Pit, Activated OTHER TESTS neg A80 Group B Rh Type ca237 K AFPTu•nor Marker 2230Alburren S $ S S S S vt s S S 214041kahno Phoionstese 823 0 40 243 249 O 4,44Suert FAvatuFSlo zits re Pan 795 RAni.bod„, Sc,. RBC w Reflex ID In❑AST 295 DOlirubin. Direct 287 nOillrutan. Total B B S 1 $ $ S $ S S $ S OM2IP ,.., C-Reective Protein OM 029493 — CA 2721 029256 CA 125 OX0 , , Calcium 11173 — CCP Ab IgG 8979 „ CIA 8334 „ Cnoustooliroun 374 „ CIC. Tour! 375 „„ Creations 402 „ DHEA Sulfate. immunoassay 88293 — Lot Ch04eSte(01, Oval 4021 „, Esiradiol r457„, Fe...on 466,, Folic Ape 470 „ FSH 8482,••, GGT 8477 x , Gum [eggs". Soren 50. Ix cute GY 1983.3 ,._. Guest GamemsSeror TOgI. LiC osca GY 8484 ,_ Glucose. Plasma GY 8483 — Glucose. Serum S 8435 hCG. Serum. Goal 88396 „ hCG. Serum. Guam 8496_ lernoolobin Aso 8168021-. Matogtoein Ate w.eAG 499_ IRO El Surface Ab Dual S 498 „ Neu 6 Surface Ag wfbilex Confirm 5 8472_ Hap C Anolsody wineries to Owns S 891431 HIV. 1(2 ACAS. 4Th H Reflex 5 31789 „ Ilumvx.vxvine S Ri 10124 , he CRP S 561 knulin 549 E S wrivirar..vie.- RI' S 07573 licaTIBE '(. Se7 S 571 ron 593 DU 599 Lead. Blood 615 DUI 606 K bone 6646 IreDoom Lb refuels. to tiougG. 'QM) S 622 orerrunin 6517 Meroaltiumm.Rsndom Uwe wiCreet Fecal Globin, Feces FIT, InSure. I 11210E ITAEHastic F 11293 Medicare Screen 718 Duteriruounr 733 „IPotzessum 745 y_IProcresteron• 746 ,Protaam 85363 IPSA, Tote 793 Reticulocyle Count Automated 4418 „Rheumatoid Factor Lii ns _APR IMonitoringI H Relies Tile, 836126 „SPA ID)0 wReflex Confirm $02 uueue loG S 4809 Sod Rate by Mod wee! L 15963 Tostosterone.Tottil. LCMSMS SR V73 Testosterone, Teta Male SR 5001 owyos Petozdass A/abodes ITP0/ S 8896 Tuglyeei ides 5 8899 TSte 5 836127 TSII w Raney Ta. Free s 34429 , . Free S 85 1.0191 i_.T3 T1UThiptali S ke S I '867 i_iT4 (Tleroxine. Toter $ !.866 __T4 (Tnyroxinel. Free J4110/4.1. TESTS (INCLUDE COMPLETE 1(51 NAME PhD ORDER CODE) Reflex tests are performed at an additional chorus. NT1 MME ,CL NI CAL erFORMATION ky( -) V , a4 n .r\A_ iii ( )8307978 CP 307978 )e 608 CHOLESTEROL —1 I - (N. t •( L35 Caieuim 2q (koruL_ S S S $ $ S S S S S S S $ S L L TOTAL TESTS ORDERED $ TN S S S $ S S S S S 644$ 0 VA Dopstiat Dray 74009 O US. Mundt weenies Microscopic 540 0 takOvnrOmehoStirk&Sliateconic 443620 O OA. Complete. e Reflex Culture 294 0 Urea Nitrogen IBUNI 9050 Unc Aria 916 0 Velproc and au O Vencellaio* ler Vitus Ate lloGI 79650 Vitamin 612fotc Ace 927 O ',Obelisk 012 617306 0 Vows D. balyerrevy.Teta. motto 891935 O Mayon DeuestAseell)- telressel 4550 4446 4485 5617 4558 394 MICROBIOLOGY Culture. Acme< Bacteria • Culture. Aerobe & Anaerobe Culture. Group A Suers' Culture. Group B Strep' Culture. Delete,* Culture, Truest' Cala unto. livounobe busby ( Anal fled SpecknonTypo GMtlivia) 0 frRR''''R trry." 11363❑ asenycvs N. paurnoa eFNATA Stool Pathogens isehnsAig..c.„, py, mos O 0/tire. MOM, Sege teen miens" 36068 H pylon Ap, EU Stool 14039 H. pylon U ea &teeth Test al O 0 & P w Permanent Stain S • Additional donde fee ID and Suotapptildlit 0.0.greani no sal og see yenta 1)...• Jacnten ran Caegiegges• af Of C Xnil War Dora, ...ones yis wine rew ego tare II VII gar. city. We. sow =Vika Nag REQLCTPI.AD 83000£0 ,;•30:13 )611)01:2;) 32i!Alf Mean Surawedlesuired fix PA. NY. Ira 8 W9 Many payers (including Medicare and Medicaid) have medical necessity requirements. You should only order those tests which are medically necessary for the diagnosis and treatment of the patient. 1.1;•30020 re Oilt32i) )2.3302E 32:;302S EFTA00304939