EFTA00304939.pdf

ens me. Quest rt I I o MY Account Diaonnstl 78300020 II I - 6 III 3233025 iii 1111111 - 0 Insurance Provided o Lob CerdSelect CI Patient Patient Service Center location and appointment scheduling REGISTRA1PN a OF APPLICABLE PATIENT EMAIL ADDRESS V5 ▪ P / 2C h YEAR l i r5r3 (PARENT ID e I MR S , BRUCE HOSKOUITZ, ?ID information is on the back. CELL MONS I Ranters PHONE NATIONWIDE ACCOUNT ' 1411 N FLAGLER DR STE 7100 Each sample should be labeled with at least two patient identifiers IN' 'WA OF INSOREDIESPONSIBLE PARTY LASI, F557 LID(E/ ) tilif WHO THAN FATIEN at time of collection. siATt MIST PALM KAM FL 33401- 3410 ICD Diagnosis Codes are Mandatory. eelHST SIRS ET ADDRESS (00, IN SURE PRE SPONSIBLE PARTY) APT e KEY • 'F Pia( ' 56115265 Fill in the applicable fields below. TE COLLECTED TIME TOTAL Yaws . . Fasting ❑AM : O PM MI. HA I Non Fasting STATE ZIP %Lim ORDERING/SUPERVISING PHYSICIAN ANO/ORPAYORS (MUST BE INDICATED) RELATIONSHIP TO INSURED C SELF O SPOUSE C DEPENDENT ) 1376970335 ACCETRIRTI,ATIMA PRIMARY INSURANCE CO. NAME be 1386702876 tIOSHOUIT2,DRUCE ( 1477952133 H0UTCHEHS,BRITTAH MEMBER INSURED ID NO. s GROUP • INSURANCE ADDRESS ) CO CIGNA ) BCBS Z+BLUECRU STATE ( i HUSK AETNA ABN required for tests with these symbols Medicare Stu May not be coveted tor the repotted dagnosi Provide ADDITL PHYS.: Dr. NNA)PIN I I I I Limited F = Has prescribed frequency rules for coverage signed Coring* & • A lest or senxo performed with teSealChierpoimental kll ABN who VN.PHYSICLIN NAME Tests B related ccveraoe limitations nommen PROVIDER Visit Clonal' r M cars sr old in Fax Results • Cleat I State ADDRESS: son to CITY STATE 21P 'ANEL COMPONENTS ON BACK OM2IP ,.., C-Reective Protein OM S 571 ron $ 644$ 0 VA Dopstiat Dray ORGAN / aISEASE PANELS 029493 — CA 2721 593 DU 74009 O US. Mundt weenies Microscopic CA 125 S 34392 ,Ilyclrolyle Panel S 029256OX0 , , Calcium S 599 615 DUI Lead. Blood TN 540 0 takOvnrOmehoStirk&Sliateconic S 443620 O OA. Complete. e Reflex Culture 10256Latent Function Panel $ 11173 — CCP Ab IgG $ 10165 [ —Sabo Metabolic Panel S 8979 „ CIA $ 606 ❑ bone 6646 IreDoomLb refuels. to tiougG. 'QM) S S 294 0 Urea Nitrogen IBUNI 10231r 'Comp Metabolic Panel S 9050 Unc Aria 8334 „ Cnoustooliroun 622 orerrunin 87800 r lipid Panellfa LI .11 C S 916 0 Velproc and 374 „ CIC. Tour! S 6517 Meroaltiumm.Rsndom Uwe wiCreet 14052 lipid Panel w/Rellee DiLDI. au O Vencellaio*ler Vitus Ate lloGI S 375 „„ Creations S Fecal Globin, Feces FIT, InSure. I 79650 Vitamin 612fotc Ace - 20210 Obstetric Panel lecterns,/ vt s 402 „ DHEA Sulfate. immunoassay S 11210E ITAEHastic 10306 L tepees Panel. Acne a/Reflex 88293 — Lot Ch04eSte(01, Oval S 927 O ',Obelisk 012 S F 11293 Medicare Screen 10314 nPenal furictonel Panel S 4021 „, Esiradiol S 617306 0 Vows D. balyerrevy.Teta. motto r457„, Fe...on 718 Duteriruounr S 891935 O MayonDeuestAseell)- telressel HEMATOLOGY 733 „IPotzessum $ _j uemeg 466,, Folic Ape S 4I 1 rot 745 y_IProcresteron• 470 „ FSH S MICROBIOLOGY @MD Hematocro 746 ,Protaam S 8482,••, GGT $ 01759 CBC (Hob. Rat. ROC. L'aBC 8477 x , Gum [eggs". Soren 50. Ix cute GY 85363 IPSA, Tote S 06339 89947 9763 APT CBC w0410.0.lact MC, ll13C. Pit De wen INR Pit, Activated B B 1983.3 ,._. Guest GamemsSeror TOgI. LiC osca GY 8484 ,_ Glucose. Plasma 8483 — Glucose. Serum GY S Lii 793 Reticulocyle Count Automated 4418 „Rheumatoid Factor ns _APR IMonitoringI H Relies Tile, S S 4550 4446 4485 Culture. Acme< Bacteria • Culture. Aerobe & Anaerobe Culture. Group A Suers' 836126 „SPA ID)0 wReflex Confirm S 5617 Culture. Group B Strep' OTHER TESTS 8435 hCG. Serum. Goal S $02 uueue loG S 4558 Culture. Delete, * neg A80 Group B Rh Type 1 88396 „ hCG. Serum. Guam 4809 Sod Rate by Mod wee! L Culture, Truest' 394 ca237 ❑ AFPTu•nor Marker $ 8496_ lernoolobin Aso L 15963 Tostosterone.Tottil. LCMSMS SR Cala unto. livounobe busby ( 2230Alburren $ 8168021-. Matogtoein Ate w.eAG L V73 Testosterone, Teta Male SR Anal fled SpecknonTypo GMtlivia) 499_ IRO El Surface Ab Dual S 5001 214041kahno Phoionstese S $ 498 „ Neu 6 Surface Ag wfbilex Confirm 5 8896 owyos Petozdass A/abodes ITP0/ S Tuglyeeiides 5 0 frRR''''R trry." 823 0 40 8472_ Hap C Anolsody wineries to Owns S 11363❑ asenycvs N. paurnoa eFNATA 243 S 8899 TSte 5 891431 HIV. 1(2 ACAS. 4Th H Reflex 5 836127 TSII w Raney Ta. Free Stool Pathogens isehnsAig..c.„, py, s 795 In❑AST RAni.bod„, 249 O 4,44Suert FAvatuFSlo zitsrePan S Sc,. RBC w Reflex ID $ 31789 „ Ilumvx.vxvine Ri 10124 , he CRP S S 34429 , 85 . Free S S mosO 0/tire. MOM, Sege teen miens" 36068 H pylon Ap, EU Stool 14039 H. pylon U ea &teeth Test 561 knulin S 1.0191 i_.T3 T1U Thi ptali ke S 295 DOlirubin. Direct S 549 E wrivirar..vie.- RI' S I '867 i_iT4 (Tleroxine. Toter $ al O 0 & P w Permanent Stain 287 nOillrutan. Total S 07573 licaTIBE '(. Se7 S !.866 __T4 (Tnyroxinel. Free S • Additional donde fee ID and Suotapptildlit J4110/4.1. TESTS (INCLUDE COMPLETE 1(51 NAME PhD ORDER CODE) Reflex tests are performed at an additional chorus. 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 ( )8307978 CP 307978 —1 I - (N. t •( )e 608 CHOLESTEROL REQLCTPI.AD L35 Caieuim n2q MMENT1,CLNICAL erFORMATION ky(.r\A_ -) V , a4 (koruL_ TOTAL TESTS 83000£0 ,;•30:13 32i!Alf )611)01:2;) ORDERED Mean Surawedlesuired fix PA. NY. Ira 8 W9 Many payers (including Medicare and Medicaid) have medical necessity 1.1;•30020 re Oilt32i) requirements. You should only order those tests which are medically necessary for the diagnosis and treatment of the patient. )2.3302E 32:;302S EFTA00304939