@ Quest gnostics” Diag UMM ao) Each sample should be labeled with ro} at least two patient identifiers > at time of collection. fe] ICD Diagnosis Codes are Mandatory. ‘4 YS265 Fal Fill in the i 1 fields t ‘ . PATIENT STREET ADORESS (OR INSURED/RESPONSIBLE PARTY) APT & KEYe TE COLLECTED TIME AM TOTAL VOLMAS. ting ‘VUPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED) RELATIONSHIP TO INSURED: O see DO spouse CD DEPENDENT & ) 1376970335 ACCETTURD AMANDA PRIMARY INSURANCE CO. NAME Nef 1336702878 MOSKOWITZ, BRUCE W { ) 4477952133 HOUTCHENS ,WRITTAR Saati SUES TG os Zeca: INSURANCE ADDRESS ABN required for tests with these symbols PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) . © OTHER THAN PATIEN ( } Cem CiewA € ) BCBS Z4+BLUECRO ( > AUSHC ALTHO PRIMARY INSURANCE re coverage ICD Codes (enter all that appl L_] UA. Dipstick Onty (UA Dipstick veRefiex Microscopic (VA Complete (Dipstick & Microscopic WH (2) VA Complete, wRefiex Culture Upese (L) Uree Nitrogen (BUN) Lyme Dasonse Ad w/Retien to Biot (p64. igh) 905 [} Unie Acta 916 (_] Vaiproic Acid 4439 (_] Varicolia Zoster Virus Ab (IgG) 7065 (_] Viternin 812/Fotie Acid 927 () Vieemin 812 tron LOK Lead, Blood ORGAN / DISEASE PANELS 34382|_ Elec Panal @10256 [_)Hepatic Function Panel 10165(_)Basic Metabolic Pane! 10231 [_}Comp Metabolic Pane! B7600(_ )Lipid Pane! (Fasting) 14852[__)Lipid Pane! w/Retiex D-LOL @20210["jObstetric Pane! w/Reflex Yi, aber eam B17306 [_] Vitamin 0, Hydroxy Tota Immunoassay 891935 (_] Vesnin DiQueetAesue0)™ for intents) ___ HEMATOLOGY . 25 Hyccse D.LOMSIMS (<3 yrs =o MICROBIOLOGY @1759|_}cec (Hgb, Het, RBC, WBC, Pit) 6399) CBC wiDitt (hgh, Hex ABC, WBC, Pr, Oth B8847 [PT with INR @763 |_)PTT, Activated OTHER TESTS 7788 |_|ABO Group & Rh Type @237 [_)AFP Tumor Marker 223[_\Albumin 234 [_JAlkaline Phosphatase @23[_)aLt 263 [_JAmylese 249 [_) ANA Screen, A nth Reston Ther and Pate i aoe Ser, RBC wiRefiex ID 822 AST 285 [_) Bilirubin, Direct 681 (_] O& P wPermanent Stain 287 [_)8itirubin, Torat 3 ‘ o for ID and DITIONAL TESTS: (INCLUDE COMPLETE TEST NAME AND ORDER CODE) Reflex tests are performed at an additional charge. anol : ; op ee cP 307978 7 1 Ay pert $ HOL CHOLESTER HHVRHNHHDHOD Aerobic & Anaerobic Culture, Group A Strep* Culture, Group 8 Strep* Culture, Genital* Cukure, Throat® B16802 |_) Hemoglobin Ate wieAG 499 |_| Hep B Surface Ab Qual Amplified Specimen Type (Aptima) ()ireocenicnt () Ureneai Ure (SalmShig Campy, 10108) Cunure, Stool, Shiga toxins veRefles 34838 () HM. pylori Ag, BIA Stoo! 14839) . pylori Urea Breath Test ONHHKCHNHHHOH < MMENTS, CLINICAL INFORMATION: lu Vr TOTAL TESTS ORDERED @sician Signature (Required for PA.NY.NJ& WV) Many payers (including Medicare and Medicaid) have medical necessity aul requirements. You should only order those tests which are medically } necessary for the diagnosis and treatment of the patient. : EFTA00304939