EFTA00305909.pdf

Health0 iagr tiCLabOratOrylnc. 0002442 - 0168002 or. Morph P.13130anaciiiiitatily Mega GJA No. 490/100708 I CAP No. 7224971 I NH No. 1629209853 LAST LAST LAST INSTRUCTIONS FIRS1 FIRST FIRST 1) please Min allol the yelew Ng Weed amain% tiding the clognosn code vecton at (Mum tenon of chit requeaston 0002442-0166002 21 Have the patient sin the Relent and Assignment ol Stoat; semen below 0002412-0168002 00024C-0160002 3) lea, Inc. will accept an Malone Demographic Sheet n sublets...le for Panne LAST UST LAST information provided it melees all required SIIIIIIPSPOI4 II I40-9 codes we Mt Part of your demographic sheet. please pr Me +copy of the Patient Problem List FIRST FIRST FIRST including al ICOJACM cabs For diagnoses. conditions. or symptoms. PhOtChins 10, <Rhea indohcluats aut hooted to order tests, should on), 0002442-0168002 0002442-016600: 0002442-0110002 order tests that we intensely necessary and reasonable MATION it last Name: Win Middle Initial: pmj„„11,1,J t 1 1 1 1 1 1 1 4,1. j 1 1 1 1 1 SP. Arts City: Cell/Home Insane: IRAN: Pip Code: Dr. Paw Ate 4487 Philbrook Squire San Diego, CA 92130 Clete ID: Phcoic ■ BAB Work Phone: Email Address: In:Ltsp.ir hotsi Weftht: 6 / 5 /15 Social Dori!, Ph Date PECIMEN INFORMA Rowing Lab. Phone PIr an KI cny oB Homecysterna Cortisol AspelnWorks LOLP & HDLP 13 Fin & Total Glucose Tolerance Test FSH Collection Date: * am/pm Fasting:3g Set H's NO oAI Reverse T3 Uric Acid Progesterone Phlebotomist's Initials Lore/ mess 14 Free & Total AO* e swan. Cyststrn-C an: dme of last dose: " IA im Fr ( 191 Feria V Leiden Sterols tN IW toe)-P O Testosterone Prothrornbin Mute& Onmee-3 s INSURANCE: Please attach a copy oF ROTH Skies et Patient's insurance card. -PLA2 Fres Ttstobletons Iron & II BC DHEA.S MTHFR Medicare Number: hLos-C RP Iron VII D SHBG 1St 0 SELF PAY: HDL Inc. will bill the patient. Frbdricon IGF-1 RBC Folios \Main 012 ASSIGNMENT OF BENEFITS HEIL 2 sdLDL LDUC DPMP Ai a mu:ten. Di I every reasonable effort to obtain reimbursement for ordered tests. I au Gelman-3 NT-pro BNP Leona Adrocriectr • Tor, re HOI. Inf to re:eait to %led co ie. its carriers, and any insurance carrier or health plan providing medical benelits to me. any 'one motion that may be needed for claim purposes. I consent to submit my sample to SIDS . tor testing. I am making an assignment of Medicare. Medicaid. and/or insurance benefits to HDL Inc. ea to myInstance: I understand that it ray insurance company pays me dreg* for services rendered by SIDI.. Inc. I am responsible for forwarding such payment to HDL, Inc. I also understand that I am responsible for any de ductibse/copayrnent. as required by my plan. Important: Insurance regulations regime MX inc. to seekpap-rent. I Permit a copy of this authors/alias to be in place of the original. Gene& Informed Consent: If ordered by my ph vessel. I consent to haeng genetic analysis performed at the request ol my physician and the results of the analysts made toilet:410 my 4...Wolin 64Y results are solely used by my physician to obtain information for therapeutic a diagnostic purposes This signed request authorues Het Inc. to perform the test and deiced° the results to my medical practitioner No tests Other than those requested by my physician wit be performed. Routine Pane s (see reverie fide for derails) O Basic Metabolic Panel 80048 • Comp Metabolic Panel 80053 Patient Signature ❑ Complete Blood Count w/dIfferendel 85025 El Diabetes Prevention and Management Panel (DPMP) • Hepatic function Panel 80076 32777 *Ca Genotype 81401 Apolpoproten A I 82172 83180 OCYPX19 (Nem' Response) o Lipid Panel 80061 Ir TI FFIFF. 81229 0Apospaproten 8 82172 CIFaCtOr nekton 81241 • Omega-3 and Omega-6 Fatty Acid Profile 82541, 82544 DH042 C Subclass 81664 0 MTHF8C6774 8.3129.9C MutatiOnS 81291 O Oral Glucose Tolerance Test (OGTT) 84631 ❑LOL.P 8 Hobe Ilsy Neal 83704 O Proihrombin Mutation 81240 O Renal Panel ❑FM/MCA 82726 0 ONO massed refer 83695 OGIamst 82947 OCYP2C9 ri •s18. MAGI chtscsao 8122781355 ❑ Noncholesterol Sterols & Stand' 82542 0 sdiot.c 83700 OHtneglotsn Sic 85036 il lEarr ill a A ung illriErallilli r LI Thyroid Cascade asK, hisNli reflexes to )4. free 71. and Ti) 70 ❑ sernecysteine 83090 LI Thyroid Panel (194.13. 14. and free T41 ❑vs.A. total 84153 r Awes ir= Wor7 l 4? rnn82565. n::.. 84431 O 83525 Additional Tests On Back 0 7 / Isaiah:manes 83789. 82570 ❑ ROC Fonts 82747. 25014 SH 844)3 Please write the test name and COT code O fibrinogen 85384 ❑ Unc Acid 84550 O14.1 Free 844)1 Ohs Cfle 86141 O Vitae^ 6.r 82607 O14 °Name. CPT' 84436 0 lisiPLA, 83698 025 hydrcoevitamin D82652 OMPO $3516 B T3. free 13 64481 8.480 ONa Cltiame: CPT' faleigNOSI5 CODE(S) REQUIRED. PLEASE CHECK AU. CODES THAT APPLY. WRITE ADOOKINAL CODES IN THE YELLOW HIGHLIGHTED SECTION AT THE BOTTOM Of THIS FORM. The codes below are listed as a corMmience. This is not an allinClulive list. INIMICRIERNIM ijoiatietes meatus, n controaid 25000 D unspent's., disorder of metabolism 272.9 OThionstotroPenia. unSPetiatd 287.5 011naertmuice. magnate rot 0 MOiabetes meatus. II untontnYkd 25002 D Screeerg for lied disorders v7791 MENTAL NSOIMMS ORPM•ftlifitaCiel, benign 401 1 C 99ectel screening for dabetes meatus v77 I Oinsulin resistance/ Dysmatabolic syndrome 277 7 00tpressen NOS. Peretove mot , 311.0 Jura:demos.% tantsecifed 401.9 OFTediabetes. abn glucose eisperglyceenia 79029 0 Obesity, unspeohea 278.00 Chiba depressor duster, recurrent episode296 30 jitypenensive heart disease, n.µgnant 401 00eCktrated/ampaired fasting glucose 790.21 BIONl a StIAPTOtAS. STATUS 0Alzhenner's dr 331.0 Jlerpenensive Man Or benign. a/oMantracer. 10.7 160 Personal history of gestanOnal diabetes VI2 21 Of atque malaise. weakness. NOS 780,79 INSPIRATORY Dhhiptinenvve heart Or benign. w/ heart (elute 402 11 0 rangy htucry of clobetes molten V180 OMemon Loss 780 93 050e (Shortness of breath) 786.05 DItypenentive heart dr. umpire w/o heart failure 40290 OHsperparaterchoidism. unspecified 251.00 Oatrormat gat 781.2 0 Dyspota. respratory Insuffiateer 786.09 Danes& NO5 413 9 0 HypoparalliwOdopt 252.1 Clad, ohcoortio4nat 7813 OCO4th 786 2 DChant pats unseen...0 746 500 Testicular hypefunown. NOS 257.2 0 Weight loss. atincrreal 785 21 Disbnotmat meat troy 793 19 Dub. name artery 424 01)14ormiser/enesocrine disorder. ttinpeOfted 259.9 ()Abnormal blood chemistry lab endings 790 6 OSeelling. mats or lump in Chest 786 6 ]Coronary atherosclerosis due mulched logn 414.6 ONututional deficiency V12 00ther abnormal hndings of. blood tests 790.99 Otiose cheese. NO5 518 89 OCardiovascutar disease. unspecified FASCVOI 429 2 OPAalnutotion. severe 262 0900.4c 0 usa and abuse 3053 Drama/ history of lung cancer V161 Diarnoly Nuance cardsnausibe disease Y17.49 Oltaalrfigratoss. moderate 263 0 0 Personal h. of tobacco use V15.82 0Astestos hiposiae, pence/OH V1584 %Family hedoryischemic heart di V17.3. OOthe. 8 cornetts deectenoes Wit $121 266 2 0 liovtine annual health check-up v700 SIMMOINIUMIN. J Carotid artery colusidenosts, wto infanta, 433.10Retarnin 0 deficiency 268 9 0 Long term (current) use of meacanons v5889 IDGCROMenia 53021 3 Alfial hbralloOn 427.3gOOsteoporosis.1405 713 CO OLOODDISOODON CRINITOMMIArt j Atnbroscletosts of ocher 'pentad arteries (non coroners/440 8 iCHspenhcarsterolernia 2724 [Ilion deficsency anerma. unspecified 2209 0Screeneu for Prostate Cancer (MN V7644 LI Athssrov.ltrunc vascular 2.12, 505 440.9 CIPare hyeergiecendernignementighteetrinu272 1 0 rotatedekleaCy leternto 281.2 00evaltdP54 "a," ENOoatill&NUMMON.MITAIOLK OHyperhpetemu. rinsed 272 2 0 Memo& denciergy. unspecified 2819 OProstate Cancer las.° istypothuicidism unsettled 244.9 °Hyped...Sena NO5 272.4 DArstmia. unspecified 285.9 Diemen prostanc nmenroohy Mehl 640 AO Additional Codes: . . _.... ... .. . . EFTA00305909