Quest (@) guest Diagnostics HAC A 17434-0 3936515-7 Epstein rob Lf PATIENT SOCIAL SECURITY # _ OFFICE/ PATIENT ID@ S Patient Service Center location FA and appointment scheduling mo is on the back. LAS REFERENCE & PATIENT PHONE # sg QORHDSKOUITZ BRUCE MD SXOONT Sef GR/UHTU. CLINICAL AME: scontss #44 # FLAGLER DR STE 7108 3 Each sample should be labeled PRINT NAN OF INSUREL/RESPONSELE PARTY (AST, FST, MADOLE)-F OTHER THAN PATIENT cry STATHIEST PALH BEACH, FL 33401 tal with at least two patient identifiers Fj *t time of collection. ae oe Ls Ls io on on PATIENT STREET ADORESS (OR INSUREDIRESPONSIBLEPARTY) APL® KEYe EON US 285 61-33-6116 .ATE COLLECTED am TOTAL VOL/HRS, C1 Fasting Lips _____ ip | CONon Fasting PP 4PUUPIN ORDERNGSUPERVIGNG PHYSICIAN ANDIOR PR Raich MUST E BE INDICATED) i ’ , it i i 4 € > 1386702876 HOSKOUITZ BRUCE WH g RELATIONGHIPTO INSURED: Osevr CO spews € } 1378970395 NARTLH ANAHER & faa MARY USURANCE CO, NAME PB VieMSth/INSURED iO NOS ~~ \/cnour® PHYS REDIPASS AUTH : > ? \\ 77 { 3 GGA CTeHR € } ERPIR DAPIRE UH & € > BCBS Z*BLUECRO = ¢ > GHPNS OXFORD HE = SS YW € > AUSHE AETRA a a € > GOLOR SOLOEH RY y Not be covered for the reported di nosis. ADDITL PHYS.; Dr, NPWUPING Jt ttt tts ay ‘tinted eed Foqueny ns fre omnos sale Aarts ON-PHYSI Test oF se omed with reseai ‘experimel PROVIbore “Tosi Has both y iced and frequency-elated coverage imitations, (Fax Results to: ICD Codes (enter all that apply) Ww Client # Gd alicate ADDRESS: eer} “om ___SSTATE._sP { 28302986 CP 302946 €) 34? CORTISOL, TOTAL ( 8 10124 HS CRP €) 859 13, TOTAL ( ) 303644 CP 203644 €) 375 CREATININE (> 549 IMMUNDFIXATION,SERUN ¢ 28 © 867 T4 (THYRDXINED € ) 307978 cP 307978 ‘ 4420 CRP 8 S71 IRDR, TOTAL 48 866 14, FREE h48338742 CP 338742 } 10108 CULTURE, STODL W/RFL ¢ 98 7573 IRDH, TOTAL, AND Ine 873 TESTOSTERDNE ALE €) 223 ALBUNTH ( 9€ $293 DIRECT LOL €) S93 LD € 8 898 TRIGLYCERIDES { ) 234 ALRALIWE PHOSPHATASE > 34392 ELECTROLYTE PAWEL ¢ 98 7600 LIPID PANEL (8 899 TSH £) 823 ALT {) 4024 ESTRADIOL {) G59 LYHE DIS IS6/H MOT { ) 294 UREA HITROGEN «1D () S509 AnHENIA <P> (8 457 FERRITIN {> 34127 H.PREU IGG AND ICH ¢) 905 UREC ACID () 243 AHYLASE «> = 470 FSH () 659 H.PHEUWN. AR CI6G> (> 6448 URINALYSIS nAcRD {) 249 AKA TFA W/RFL IFA 0% 08 483 SLUCISE {> 22430 H.PREUHD. Al CICH> ¢€ > 790% URINALYSIS REFLEX %) © B22 AST € 8 496 HOSAG H/RFL CONF {8 622 HASHESTUH 5463 URINALYSIS, COHPL {) 10165 BASIC MET PRL {) 35645 HCV RNA, QR PCR (>) 636 MERCURY, BLOOD $38 17306 VIT D,25-DN, TOTAL {) 852 BETA 2 HICROCLODULIN( D€ 808 HDL CHULESTERDL {8 48 PLT SODIUM CITRATE_¢-9 «927: VITAMIN 112 {)} 287 BILIRUBIN, THTAL ¢ 6 509 HEHATOCRIT {> 733 POTASSZUn SOURCE: (8 4698 CA 19-9 {8 510 HENDCLODIN (8 @B47 PRD TIME WITH IHR ¢ ) «(91664 C DIFF TOXIN W/RE { )@ 29256 Chi25 {8 496 HEHDELORIN Aic <)> 74? PRETETH ELECTRD. {> 4475 CANPY CULTURE {8 303 CALCIUM {) Si2 HEP & eH {> 754 PRETEIN, TETAL, (S) ¢ > 394 CULTURE, THREAT € )@ 6399 CBC <DIFF/PLT) {) 4848 HEP B CORE I6n AB {5363 PSA, TOTAL _-%8 395 CULTURE, UR ROUTE € 2 2759 CRCCH/H,RBC,WBC,PLT)( > 8472 REF C AR N/REFL HEV 8837 PTH, INTACT ¢ CAL {2 11290 FECAL XNMUNDCHEN € 38 978 CEA ( 8 10306 HEP PHL ACUTE W/REFL <{ 28 763 PIT, ACTIVATED € >} 31293 FECAL InmUNDCHER € }@ 334 CHOLESTEROL ,TBYAL ¢ )@ 10256 HEPATIC FUNCTIOR PHL_( > 4428 RHEUMATOID FACTORS ¢ 9 681 BUA AND PARASTTE () 374 0%, TOTAL (> 91434 HIVI/2 AG/AB,4 WAFL Se 809 SED RATE BY NED WEST ¢ > 10019 SALN/SHIS, CULTUS (> 20233 COMP ETA PHL {) 32789 HDHBCYSTETRE ¢ 28 864 T3 UPTAKE {> 30264 SHIGA THX, EIA By TONAL TESTS: (MUST INCLUDE COMPLETE TEST NAME AND ORDER CODE.) Reflex tests are performed at an additional charge. * Additional charge for ID/Susceptibitity studies. : - “47436 © 17436 a" 3936515 3936815 aim Wodicala andl Wescala) hee risalca 17436 tian Signature (equiv for PA, NY, Rd & MWY} reaene ona . 2S ve medical ns sm REQRTF re Seas nel necessary dnl arerieraamrentabey = = anaes = Ownee Bingo! EFTA00304861