EFTA00304861.pdf

atroltic 0 My Aocou t rp fref in N nuns= ProAdotl • 11111 111111 1111111111111 REGISTRA OTAPPUCABLE) YEAR SD El Lab CardGelect DATE :::111 n OF BIRTH I I 17434-0 3934515-7 PATIENT SOCIAL SECUNTY I/ OFFICE/MENTOS Patient Service Center location I I UCA/110SMOUIT2 BRUCE MD and appointment scheduling ROOM • LAB RIPERENCI• PATIENT PHONE • IXDUKT all CR/UNIU.CLINICAL information is on the back. WM: 1411 N FLACLER DR STE 7100 ) Each sample should be labeled PAINT NAME OF INSLPED/IFSV0NSBLEPAMPAST. RASE OS:VW- FOROBIANFATENT MIEURT PALM BEACH, FL 33401 with nt lean two patient identifiers at time of collection. I ' , t I ; I I I I I KEY/ SERENTS/REETADORESSIORINSUREDRESPONSIBLEPARTO APT' rileicm?,6115265 561-833-6116 hATEONIECIED TWO r7 Am TOOLVOLAIRS. IWesting STATE ZIP G PM HS O Non Fasting CITY JPEUPIN ORLIEFUNG/SUPERVISANO PHYSICIAN ANCYOR PAYORS MST BE INDICATED) I I 1 , 1 ; 1 1 i i l l I I ( ) 1386702876 MOSXONITZ,BRUCE U nEtATIONSHIPTO INSURED: 0 NAP 0 DITIVOINT ( ) 1376970395 HARTIN,ANANDA PRIMARY INSURANCE CO. NAME I 1 1 1 1 1 I I I I eismriaft /INSURED ID NO.0 • PHYS MEDIPASS AUTO # (9) ( ) CCn CIGNA ( ) ENFIR EMPIRE UN MSURANCE A ( ) DCBS PEOMECRO ( ) GAMS OXFORD NE ( ) AM AETNA STATE ZIP ( ) UNTO UNITED HE L i ; I I ( ) COLOR ;OLDEN RU Medicare 411= May not to covered to the reported diagnosis. ADINTL PHYS.: Dr. Limited F • Has pros:Axe frequency ides for covorego. eir OiNaNYMCIAN NAVE LOS Coverage de .-. A leSt or service corlomme with research/experiment kit A when PROVIDER Tests B - Has togs diagnosis aro hear onCY-lolal CO"Ine FnItath'IS Wean t ax Results d Gamma to arts ADORESS: 'owlet CITY STATE_ ZIP ( )0302946 CP 302966 ) 167' CORTISOL, TOTAL 4 )8 10124 HS CRP ( ) 859 13, TOTAL ( ) 303644 CP 303644 ( ) 375 CREATININE ( ) 549 IMBUNOFIXATIOR,S£RUM ( )8 867 14 (THYROXINE) ( ) 307978 CP 307978 i y" 4420 CRP ( )8 571 IRON, TOTAL ( )8 866 14, FREE 0338742 Cl' 338742 ( ) 10108 CULTURE, STOOL 11/RFL ( )8 7573 IRON, TOTAL, AND IBE.fr4r 873 TESTOSTERONE,MALE ( ) 223 ALBUMIN ( )8 8293 DIRECT LDL ( ) 593 LD ( )0 896 TRIGLYCERIDES ( ) 234 ALKALINE PNOSANATASE( ) 34392 ELECTROLYTE PANEL ( )8 7600 LIPID PANEL ( )8 899 TSH ( ) 823 ALT ( ) 4021 ESTRADIOL ( ) 8593 LYME DIS IWO BLOT ( ) 294 UREA NITROGEN (DU ( ) 5509 AMMONIA (P) ( )8 457 FERRITIN ( ) 34127 RAINED ICS AHD IGO ( ) 905 URIC ACID ( ) 243 AHYLASE ( ) 470 FSH ( ) 659 M.PNEUMO. AB (1CC) t ) 6448 URINALYSIS MACRO ( ) 249 ANA IF* U/RFL IFA ( )0 483 GLUCOSE ( ) 21130 M.PNEUBO. AB (IGN) ( ) 7909 URINALYSIS REFLEX. ( ) 822 AST ( )8 498 HASA8 U/RFL CONE ( )8 622 MAGNESIUM 5463 URINALYSIS, CIMPL ( ) 10165 BASIC MET PHL ( ) 35645 NO RNA, OH PCR ( ) 636 MERCURY, BLOOD J.48 17306 VII 8,25-ini,Toint ( ) 852 BETA 2 NICROGLOBULIN( re 608 HDL CHOLESTEROL 18 PET SODIUM CITRATE...A-1 927 VITAMIN 012 t ) 287 BILIROBIN, TOTAL ( )8 509 NEMATOCRIT 733 POTASSIUM SOURCE: ( )8 4698 CA 19-9 t >8 510 HEMOGLOBIN 8847 PHD TINE WITH INK ( ) 91664 C DIFF TOXIN IMRE ( re 29256 CA125 ( )8 496 HEMOGLOBIN A1C 747 PROTEIN ELECTRO. ( ) 4475 CAMPY CULTURE ( >8 303 CALCIUM ( ) 512 NEP A IBM 754 PROTEIN, TOTAL, (5) ( ) 394 CULTURE, THROAT ( )8 6399 CBC (DIFF/PLT) ( ) 4948 HEP B CORE IGM AD 5363 PSA, TOTAL 395 CULTURE, UR ROM ( )8 1759 COC(H/H BBC NBC PLT)( ) 8472 REP C AD N/REFL NCV 8837 PIN, INTACT 4. CAL. ( ) 11290 FECAL InnunocnEn ( )8 478 CEA 10306 HEP PHL ACUTE U/REFL ( )8 763 P11, ACTIVATED ( ) 11293 FECAL INDUNOCHEM ( )8 334 muumuu:rum 10256 HEPATIC FUNCTION PH ( ) 4418 RHEUMATOID FACTORS ( ) 681 OVA AND PARASITE ( ) 374 CV, TOTAL 41431 NIU1/2 86/00,4 N/RFL 809 SED RATE BY no NEST ( ) 10019 SAIM/SHIG, COLIMA ( ) 10231 COMP META PHL 31789 IMUEMUTEINE ( >0 861 T3 UPTAKE ) 30264 SHISA TOM, EIA XBIALTESTRherSTiNCUDECOMilthiEMEUNAMEANDORDERCOW) Reflex tests are performed at an additional charge. * Additional charge for ID/Susceptibility studies. 17436 17436 WNW, CUNICAL INFORIAATION: 3936515 3936515 TOTALTESTSI I ORDERED L_ Many payers kinciading ?dedicate and Medicaid) have medical wecessity REOBKTP 17436 17436 CEA &green flequkad for PA, NY,NJ &WV% welch are medically requirements. Yes shoild only order those tests patient •- 3936515 393651S necessary tat the diagnosis and treatMett aline .:,a4‘Wilkays.cABaegNVIESTX"OhohteftdRichmaecrearNts& —1-tisaa"k-ale--Itti---Tresnyorsaum EFTA00304861