@i Quest Diagnostics” {Mn 3233025- BRUCE MOSKOWITZ, MD OUN'* WATTOHMIDE ACCOUKT {411 # FLAGLER OR STE 7100 AES” WEST PALM BEACH, FL 33401-3418 PRINT NAIME CF (NSUREDYRESPONSIGLE PARTY RAST, RAST, MADDLES -\F OTHER THAN PATIEN PATIENT STREET ADORESS |OR INSUREDIRESPONSIBLE PARTY) APT@ KEY # LEP \TECOLLECTED.—SC«SdST Clam TOTAL VOUMRS, _ Oo PM HR STATE ap PYUPIN ORDERING/SUPERVISING PAVSRAN ANDION PA Take (MUST BE INDICATED) RELATIONSHIPTO INSURED: Ose C spouse CO DEPENDENT ¢ ) 1376970335 ACCETTURD,ANARDA Agf 1386702876 MOSKOWITZ ,URUCE W (>) 1477952133 HOUTCHENS ,WRITTAR PRIMARY INSURANCE CO. NAME MEMBER / INSURED ID NO. # INSURANCE ADORESS PRIMARY INSURANCE C >) CON CIGHA (age ETM a a ( ) @USHE AETHA ABN required for tests with these symbols Meficare a May rot be covered for the repartod diagnosis. Provide ‘_ 1 11 jas prescribed frequency ru! cover Aor fva: nryurin Coverage Bed ete or service performed with rear experrertal hit ON PHYSICIAN 0 | a 4 sis : [Fax —— to’ : ; PANEL CO ONENTS ON BACK ORGAN / DISEASE PANELS 34392 [Electrolyte Pano! @10256 [_)Hopetic Fuaction Panel 10165 [Basic Metabolic Pane! ‘Comp Metabolic Pans! 87600 [_)Lipid Panol (Fasting) 14852 [_)Lipid Panel w/Refiex D-LOL @20210[_)obstetric Panel w/Retlex (10306 [_)Hepetitis Panel, Aceto w/Raflex 10314] )Renal Functional Pane! HEMATOLOGY @510[_}Hemogiobin 2509 [_]Hometocnt 1759 [()cec (gb, Hct, RBC, WBC, Pet) (BG399(_] CBC wD ay, Hex ABC, WC, Pr. OF} Bg347 (_|PT wih INR 7909 (_] UA, Dipstick weFeflex Microscopic 5A63 __] UA Compiete Dipstick & Microscope UA, Complete, whtefex Culture 294 _] Urea Nitrogen (BUN) 905 C) Use Mess 916 _} Veioroie Acid 4439 7) Varicetis Zoster Virus Ab ligG) 7065 |_} Vitamin 812/Folic Acid 927 F vaamin 812 B17306 [_] Veurrin 0. 25-Hydremy, Tam, Imerencanas B91935 [_} Viernin D(Questtensel™ fir infants} < abanawne MICROBIOLOGY SNMENHOHNHHHODHEOHEOD 3} Sowen (Required) Culture, Aerobic Bacteria* Culture, Aerobic & Anaerobic* ticulocyte Count, Automated mmatoid Factor Sabzen 6799 T)APA iManitoring) wiRefiex Titer Curture, Group A Step* C763) | PTT Activated 836126 [“]aPR (0x) wiRafiex Confirm Cunure. Group 8 Strep* OTHER TESTS 902 Culture. Genital’ 7788 [_]ABO Group & Ah Type Y @e09 Culture, Throst* = AEP Tumor Marker s 15983 Cuture, Urine, Routine Dine. dv ing Albumin s 873 Alkaline Phosphetese ° bes tine. B ANAT ere ‘oe : 836127 W)1SH wiRetiex T4, Froe (SaineShigCamp, ANA Screen IFA with Petter MerandPemm = S 3442913 Free . 101087) Cutture. Stool, Shige toxins wRet Antibody Ser, RBC wiReflex ID ¥ 869 hrs, Total 340387) + pylori Ag. EIA Stoo! s 8961 113 Uptake 14839) # pylori Ures BresthTest 8 6g67 ~ [Eira cTmyroxing), Total 681] 04 P wPnrmenent Stain s for 1D and Susceptibit DOITIONAL TESTS: CONCLUDE COMPLETE TEST NAME ANO ORDER COOL) Retlox tests are performed st an additional charge. ar benann' [even sopnen horton’ Pr po ee eae wo Case WNE- Prosphat %e tes Cole 442 EZ Qore Bide © REQLGTPLAB ‘ 35- alourn ay Wr. Uline ( resid 7830092) 1273925 pe TOMMENTS, CUINIC AL INFORMATION: TOTAL TESTS [| 3233025 ORDERED al se an ein A WARE: _. 78300020 78300020 hysician Signature (Required for PANY, NU & WY} paye! ars (lncladiag Oi 9 io i) whit ica ail 0308 ssaeee _ Teletsary ter the dlageosis amd reatmnent of the patent EFTA00304938