EFTA00304938.pdf

BELLI*: nod. PAS salt PAPAL Waal. Pavel. C My Account ;._?sit\ n I III II iii I o Insurenos Provided GtSTRA N • IF APPlICABLE) i Lab Catd/Ssui I ( Priem 3233025- PATIENT EMAIL ADDRESS WNW 0 • / Patient Service Center location and appointmen scheduling )!RUCE MOSKOWITZ, ND information is on the back. Cell PH NATIONWIDE ACCOUNT Each sample should be labeled with 1411 N RADLER DR STE 7100 at least two patient identifiers 1( ) J. 'l OF INSUREDTES•131.38if ',VEY ALST.F331.6000 ODES TWA We. WEST PALO DEACH, EL 33401-itill at time of collection. ICD Diagnosis Codes are Mandatory. NT STREET ADDAESS ICR CSuKEORESPONSIBLE PARTY) APT I KEY* nm" (56624S Fill in the applicable fields below. ME COLLECTED nia AM TOTAL Yam% Ij I Faettog OPM pAL _ HR D Non Fasting PIARIN ORDERING/SUPERVISING PHYSICIAN ANO/OR PAYORS (MUST BE INDICATED) RELATIONSKIPTO INSURED: a SELF C SPOUSE 0 DEPENDENT ) 1376970335 ACCETTUR0.000800 PRMARY INSURANCE CO. NAME Ser 1306702076 HOSKOMIT2,0RUCE ( i 1477952133 HOWICHENS,PRITTAN MEMBER! INSURED ID NO. • GROU • ( CCB CICHE ( DOS Z+DLUECRD i HUSK AETNA ABN required for tests with these symbols Medicare a- May rot become] for the reported magncsis. Provide Limited F =Hes panted frequency rules tot CO:MCA signed I ADCITL PLAYS.: Dr. Coverage & • A test or service perforeed weiresearchtexcerrental kit ABN who Tens B = Has DILL thongs nib fisionvelatad retovese linsiatert aaraintai DINS to Mgt viols ADDRESS. twits CITY STATE ZIP PANEL CON NENTS ON BACK C-Reactive Protein KAP) 61571 Iron S 6449 0 UA. OtPladt 0 ORGAN / DISEASE PANELS *2903 CA 2729 593 LOH S 7903 0 UA Diana witelle: Mlgoscogc *39356 CA 126 599 Lead. Wood TN 54130 ua. Compraelp*eha Micemeora 34352 7_,ElectraIns Panel S *303 Calcium MICOMEllaesuc isaction Panel 615 U LH $ 030290 UA. Complete, yeReaex Cuturti 11173 CCP Ms ig.1 606 0 ow. s 314 0 Wee Nitrogen MUNI 10155L20mskbr.uprorrusi 897$ CEA 6648 Lrit emus aa amena goose.le* S tenIEComp Metabolic had S Onolestaiol. Total 9050 uric AgE 8334 '.4672 Magnesium $ 916 ❑ woo* Acid 87.00DUpid Panel IFaStlagt S 374 CC Total 6517 lifirnabutrat. Rargam (Asia merest 4439 ❑ Varkteaa-ZOStet VirusAt. IMG) 14152DipI d Pa n al wfibillex DADL S 375 Croatians S Fecal Globe% Faces . FIT InSarST4 7015 0 Manse 1112figic Add DE212100 Obstetric hell valleigi V.1.5 402 DMA Sulfate. Immunoassay 1t200❑ Diagnostic 00243 1.01. ChaleaterO1. Dract S F MEI Macicare Scram 927 O %%min B12 'DIEGOEDICipstitis arab* vallellar 5 0 Van*, 0.75.410acy.latOrrograma 1/314 RenalFungal Panel S 4021 Estragol $ 817306 @el Marion S 718'Phosphorus 891935 ❑ Moran GeOurageanCL` kriging 466 Folic Abd 133 ;Potassium S EISIORHomaglogn I. ESN 745 ,.,Progsterone S MICROBIOLOGY 4 470 Acitactin •3309 Hematocm L 8482 GGT S 746 etraOcec (HO. MCI. MC,MSC. PIT) L 85363 —I•SA.TOMI $ Saga IlismisEl on.HCBC vot•fl figi.Hit litttWOC,FitOR) I. 88847 PI vain IPIR B 8477 Dame Gisialx:a Sow 9491 OS oat GY 19833 Gum Emaiivai Myer TOot LOtes• CY 8444 Glucose. Plasma GY 793 _Ratictilocni Count. Automated 4418 Rheumatoid radar S 4500 Curture, Aerobic Berne.' 4446 Carture.Inaram a Amerob.c• caure, group A sver PTT. Activated B *290 RPR iMondaringl mllellex Titer S 44$ Bpi Glucose. Serum 636126 RpR tr0CI peRallea Consren S 5617 Culture: Group B Stvp• 0435 BCC. Sarum. Ousl 5 KS — Rubel* IgG S Culture. Genoa SIM 100, Serum. Guam 45N 7788 DABO Grouts & Rs Type y Sad Rate by MMINest 394 Cuhure.Tnroat• (4237 ❑ AEPTumor Market S BIN Nomoplogn Mc 16913 Teatosnrons,Total. LCMSSAS SR OA" Urns. liouga•Onc roses zzy Miming S 616892 Hemoglobin AlP meAG 873 _ wove/one. TOM. mo• SR earn tied lipealeneeTYP• Cftniead 234 Alkaline ProsphAase $ 439 Hap B Surface Ab Oval 5081 Tbrad Pemoidaieamecclies IMO/ O Inemnital • Uglaral U Lave 491 Nev B Surface Ag wflelle: Conform 8896 T $ ANAT it23 0 aer $ 6472 _ Map CArlottatty aelitelex to Gape S 243 0 Amyrne $ 8899 891431 i4M112 AGAB. 4th smflx S 836127 nr Tsig :Hce sgelnox ik" TI, Free Stool PrnI10610s• issysnocamm 249 O anarneniarn weroatter Nam $ 31789 Homorystemt 1029 73. Fns $ 101058 Ultra. Stool Shim toxins voRall 7.6 c Antibody Sc., ROC A/RAW t V C ns CRP 869 111 Tete S H pylon Ag. EIA Stool 072 CAST $ ®1507 mum 6861 " T3 S 148390 Pi pylori Urea 8reatkTest 225 C011ilybol. WOO 3 PM' mmureflxiiiim OFEL 8857 m anytounel, tool S EllLI 0 40Pwiromainent Stain 117 DBiSrutin.Tosal s 07573 bonnet.% sr, s B866 ,,_ T4 iThyrounel. Rae s • Additional Marge Rae ID and Sesamilbll Owe Gs.Manta Iv neaNisp.)14 essinol 0naula r..• COI TIONAl IDIS (INCLUDE C0/.0ETED.ST /Oat Mi0 ORDER CODE) Mlles tests are patterned Men additional charge. larglerges Wen. I 2•00•11•60 'Anna to want 41400/0.6.14100. ••••Cainette 31/¢/Ac Lia )0307978 CP 307978 ( )e 688 Rit CNOLESTECOl t t CO 441& C‘ 0nt RULGTFLAS a lagPCS0C NFIL( j(p35-Caiawm 2(4 hr. Lime- :OMME/175,CUNICM INFORMATON:1Otelliat in& TOTAL TESTS 78300020 78300020 3233025 76100020 123302S ORDERED 3233025 Midas Slgra6lreiNqulrSSld PA NY, Nib VM Many payers (Including Medicate sad Medicaid) have medical necessity NAME: __ _____ 22300020 70300020 requirements. You should Daly order those tests which are medically 323302S 3233025 necessary for the diagnosis and treatmen of the patient. EFTA00304938