ae 0092442-0168002 oto, S , ry - FIRST FIRST. FIRST heceon at he ver bench of tis reqcason | 0002442-0168002 0002442-0168002 0002442-0168002 2) Mave the patient sign the Release and Assignment of Benefits section below. om + e ims +3) MOL, Inc, will accept an In-touse Demographic Sheet as substitute for Patent Last Last. LAST. Information, provided f comtains all required information. If ICD-9 codes are not part of your demographic sheet, please provide a copy of the Patient Problem List FARST, RST. FIRST. inchading ail ICD-9-CM codes for diagnoses, conditions, or symptoms. NOTE: Physicians (or other individuals authorized to order tests) should only 0002442-0168002 0002442-0166002 0002442-0168002 order tests that are medically necessary and reasonable. _ REQUESTING PROVIDER/LAB/INSTITUTION AS & courtesy, HDL, Inc. will make every reasonable effort to obtain reimbursement for o thorize HOL, Inc. to release to Medicare, its carriers, and any insurance carrier or health plan provid benefits to me, any information that may be needed for claim purposes. | consent to submit my Inc, for testing. | am cnciing an cotgnsnent ot Meccan, Medicaid, and/or insurance benefits to HDL, inc. Bill to my insurance: | understand thet if mi insurance company pays me directly for services rendered by MDL, Inc. Bam rearenalate for forwarding such puyenent 0 WO. Ine. | also understand that | am responsible for any ductible/copayment, as required by my eaporteat: mewrance Parva & covy tf ts euthorteation tbe Wt pance the ori sician, | consent to having genetic analysis performed at request of my physician and the results of the made available to my physician. My results are solely used by my physician to obtain information for therapeutc oF diagnostk purposes. This signed request authorizes HDI, Inc. to perform the test and disclose the results to my medical practitioner No tests other than those requested by my physician wil be performed. Routine Panels 4 io Complete Blood Count w/differential , Cy Diabetes Prevention and Management Panel (DPMP) Upeor in Partich get ay = ‘$2777 | |C) Hepatic Function Panel |C Lipid Panel size) ||C) Omega-3 and Omega-6 Fatty Acid Profile Cospade 81291) Oral Glucose Tolerance Test (OGTT) DLO & MOL? (by NR) 81240 | 0) Renal Panel Fp th enw een Deiucose on 2C3 |*2 *3) & VKORCL163%in4) 8122781355) |) Noncholesterol Sterols & Stanol . - Ditemoglobin ate 93036 | PU ornecor- tung "53520, |C) Thyroid Cascade (TSH, which reflexes to T4, free T4, and T3) Dvomocysteine 83080 total 84153 (CO) Thyroid Panel_(TSH. 13, 4, and free 7 Diesutin 83525 Additional Fests On Back Drecrolate 82747, 85034 PT ts s4ee3 | (Please write the test name and CPT code Diuric Aci 84550 O14, free 84439 | ny Dviamins,, 82607 Br 4 84436 arn ET D125-thydrony- vitamin 0 82652 13, free essai | OName: cel. 84480 | (Name: DIAGNOSIS CODE(S) REQUIRED: PLEASE CHECK ALL CODES THAT ‘APPLY. WRITE ADDITIONAL CODES IN THE YELLOW HIGHLIGHTED SECTION AT THE BOTTOM OF THIS FORM be ted a T Ot al ve list 280.02 Dsoeeeing {or lipid disorders 401.1 OsSpecial screening for diabetes mellitus v77.1 Olinsulin resistances Dysmetabolic syndrome 277.7 depression NOS, Depressive disorder 311.0 401.9 CPrediabetes, abn glucose hyperglycemia 790.29 278,00 CIMajor depressive disorder, recurrent episode 296,30 SH ypertensive heart disease, malignant 402. |Elewated/impaired fasting glucose 790.23 SMypertensive heart dz benign, w/o heart talture 402.16 C)Personal history of gestational diabetes 12.21 Oi Fatigue, malaise, weakness, NOS Hypertensive heart dz benign, w/ heart failure 402.11 Ofamily history of diabetes metirtus V18.0 DO Memory toss 780.93 (2508 (Shortness of breath} Hypertensive heart dz, unspec, w/o heart failure 402 90 CO Hyperparathyroidism, unspecified 252.00 DAbnormal gait 781.2 CXOyspnea, respiratory insufficency Angina, NOS 413.9 C)Hypoparathyroidisen 252.1 Oltack of coordination 781.3 OCough Chest pain, unspecitied 786.50 C) Testicular bypofunction, NOS 257.2, ChWeight loss, abnormal 783.21 DAbnormal chest xray 793.19 CAD, native artery 414.01 }KLHormone/endocrine disorder, unspecified — 259.9 ClAbnormal blood chemistry lab findings 790.6 CSweiling, mass or hamp in chest 786.6 Coronary atherosclerosis due to calcthed lexon 414.4 Q)Nutnitional deficiency V12.1 DOther abnormal findings of blood tests 790.99 Dung disease, NOS $1889 DCardiowascutar disease, unspecified (ASCVD) 429.2 O Malnutrition, severe 262 OD Tobacco use and abuse 305.1 C)Famity history of tung cancer Vvi6.1. JFamily history of cardiovascular disease 17.49 C]Mainutrition, moderate 263.0 OPersonal hx of tobacco use 15.82 Asbestos v15.84 jBFamily history ischemic heart az V17.3 ClOther B-complex deficiencies (Vit 812) Doutine annual health check-up v700 Cities Carotid artery ceclus/stenosis, w/o infarction 433. 10§Q Vitamin D deficiency Atrial fibration 427.312 Osteoporosis, NOS Atherosclerosis of other specified arteries (non coronary) 440.8 XC Hyperchotesterolemia 2720 Olron deticiency anemia, unspecified 280.9 C)Screening for Prostate Cancer (PSA) atherosclerotic vascular dz, NOS 440.9 C)Pure hypergiyceridemia/Hypertrighceridemia272.1 O)Fotate-deficiency anemia 281.2 CiBievated psa 2722 Canemia, deficiency, unspecified 281.9 C)Prostate Cancer “THypothyroidism, unspectied 2724 OlAnemia, unspecified 285.9 OC)Benign prostatic hypertrophy (BPH) Additional Codes: EFTA00305909