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N. eisensa vood,thfrAtioviv 211 ii:-,.r3 V sage gc:: it: la : , " io Mr 44 E 61th St ii To find the nearest patientNe ii NY 10045 NYN service center, visit wvnv. labcorp.com orcail 888- IABCORP (888-522-2677). 37 len 092-o RS2553-AEOREIL. YD 1 ECK tOtE )4 -7 MIEN) NIL) )S I I SPOICARE 17 INSURANCE 1XIIIN 10170RD IOW( IISPIRI slur CR :SCPTI ICISNA NC SKS C )CINNA VETNAC /AETNA NON SAD ;WU METRO PLUS HPI ININTI 111EALTONE1 AVM 7USI GRUNT IRTAEI )61TAIN/AIT 1RI1E( )UNITED SHURE ARAI thANNA CARE-NY HEM MUM* AC PITS rRAPt )RAISER PiRRANC 371044 371061 I 371195 I *tot S.AT sanydimons .},}14}7/M ORGAN See, 322744 vrhopuNCroke no%tapCJI. OR DISEASE PANELS reverse tor components MAIHepatitis Panel 80074 Me VERSA t}liellEfSIMa ALPMABE 006827 120766 PRI . .4., MP 04ARTOAMP ruin ,a, '. CAUCOIABINATION TESTS L n si R ALPNABENCAUCOIABINATiOti WI140144. TESTS I Monondcleosis Test. Ow, 86308 ea R LpoProfile• r iel.: @ Phenoteibital (Ltrinar) 80184 Phenytoin (Orland/1e) sows CD Phosphorus 84100 Potassium 84132 Prceactin 'sue 84153/G0103 PSA. Free: Total Ratio' :I ' Prothorrbn Tat (PIMA 85810 (E) PT end Pa Acevated eras PT7 Activated 85730® Fade. e3431 ig) APP 82692 ( i), Rubella Antibodies, KID 88782® Sod Rate. Westenyen 85652 C) 84295 g) Testosterone. Total 84403 lajl . Tease/ Warcettlitten 84403 Theophylline 443i98 ) Thcmacmafta° ;•-••^41) Thyme/fn. (}4 84436€) MLR., 84439: t ponnsemnin coxed, r,... Triglycerides 844781g) TrIlOdOthyronlne (Ts) 86480® 74Uputke 84479® • N. 3rd generagon 84443® Acid 84550@ nnalysts 8 m4A= 81803 la) 11aIrit D. 25-Hydroxy 82306 la ne G A Rigte, (Gtee OAT 86140 0 •, CaSIMPRItel Pei 88141 @ Carternuetine (Tegrelce) MSC@ CEA wen rig) Cholesterol. Total 82485 @ Creabrine 82565 Eg (Limon) 80162 @ E add 82870@ Kwraei 82728 ® Fs4 a d ui am (ig 82977 @ Glucose. Pasma 82947e &cost SCUM est2 (g) U3R314.804/16als ?way, Pa70.3 C) pc°. en so scull 84782 c) HDL Cholesterol 83718 th-,-,), moglobln A1c 83036 leo efixtAAriftaly, iv gang @ ,,., Hop B Surface Mbbody 436706 ME..4 He943 Surface Antigen 87340 @ 093c0 0 HIV41/02 Antitcdes' 86703 0 1.02449b:des* 41018.1 85703 ID Hp7ifintkaa Breath 83013 H SW Antigen enge © ardIEC ms nmw miww 83515 LipidCescede =4.4.4@5 Lithium (Eakalith) 80178 83735 fn 006189 884247 007401 001024 001180 004455 01 1947 005199 020321 005207 Wer302. -10r80238028/9itis °°°022 006197 005215 001198 °°42 26 070301 007338 3" °" 001149 001974 082945 001172 002188 001156 004259 00t 00 ‘,Q8 _ — - _ _ _Sedum _ — [repeated 3 times] TAT _ — .. . LAO 322758 303754 322755 3037 236010 221010 349926 028142 005068 005041 005249 005033 005025 15179 1409abolt Panel (8) 60048(D Melt* Panel (14) 800S3 ( 1 Electrolyte Panel Booed@ Hoak RUI1C191 Panel (7) 800261g) Panel seem@ UFA Panel ALOLniCe. Rade 80061@ Upid Panel yertONDL Rao WWI® Uticl Pans tonna eons BOWL® Renal Function Panel 03069 EMT°. CNIY NOM w Pt 85025 CBC to Claw Plt 7,0 asoi4e Hintatoult 850,8 (0 Honvglotel Pleat Count 85049 c ) RBCCOUn1 seggi (a) Mt Cant 85048 ing Onaentracta ARC Co.nt egtli Mil 0074 002139 001065 001370 007385 004515 304698, 028480 0011}5WT 001818 001032 034556 ce4415 001925 0001 errp453 036495 — — Dgoxin - ALPHABETICALCOMBiti 006049 001081 001107 C015445 001396 164855 001123 00081 001099 001040 11 1016 ADON TESTS ABO and An raw., we et AHLrnin 42040 An Alkaline Phosphates° 84075 erigli ALT (SGPT) sue° .n. Arrefese a2150 i, ) AnInucloar mtioodres 86038 0 '• (SOOT) 844500 snd Faye "` gr. cD EiSka). Total n 82247m BUN 84520@ Calcium 82310 'el 038510 144065 1/3•4514bAbVerlicaem 083924 t 180836 180704 001321 00111 351948 — 007708 f I 1537 ..,88,,,. .• 08231143092 linlooThrma.‘ ) 0800.2: 08231143092 D8231143092 08231143092 D8231143092 08231143092 08231143092 L Name (La*Fm* Sex Date: 129th Collection fine Fasting Cclection Date Unnehrshol 44,4 Ores WO Day 48 20 0 No hrs_vol_ lame (Las! First /1-,,s Nins7Symptorns in iCGCM format in efcci at Da of porno* x flosotat Palters Stattz. (i In Patent O OhA-P859.1 K Non -Pa ant Pergnr //cf. 31-ReerPhozazis-virsq K(3;°I . V72 ft G') NYC— N ?Mar Ineurenoe Caere Ds LA C R5 1 4 - 055C1 7 Groups c#2 17 .2_c2 0 Insofar= Address Name of Insured Person Inaumnce carser 3 0. .1->s:fp pl.' Cr “ t OM" Insurance Address. Name of ',footed Person Relationship to Patient Rslatonship to Patient ff(Mpopt4 Nerve iiiikiceid State I 17t4AblIgS/AltlabesiviI9Srh... I COP144I0C1C/D/PlitOgriliCt... I ISH.LN)Pros I Fs-trans, LCAS, tnde Sci Employer Name Ptrif;man's Provider It Work.," Comp nYea Nome of POliCy Molder (4 O41erom from patient) Address of Policy Holder CM APT Stab ZIP tan an= St sem of alga no use arse Mead Nato tei MINN that WO. Nan mum raomstuf mines re non bt May areas me as sa u '— X Ler.. Spits.) er to Determining Necessity of ABN COInpieben on reverse ootVf 00 ( r - O Yr 27110137 &Mr ok_r( oL STD Ofl.EATESTSIMOt7IDUALPROk s2s-r 9-66 O 0 it OZ-0 o 931? /6496e— CCV.06, NYS ENDOCERvix 71 THROAT ; STOOL r uarram it OTHER SOURCE: 008649 008482 008334 008540 188132 188139 180810 182949 008623 008144 008169 008342 iJ MUHL 7 180039 180021 180060 180055 180010 183194 183160 180089 188056 88052 910343 Chronc Kidney Dsease Report Cardwascetar NO<ASSesvnenllielX1 Nast order art 36194E-1pd Cascade 6842474MR upoProlie Alpe panel) 910385 0974 Meth C Naval& CUtue t 87070 FvnOPSCultureP 87101 Grater Cour*. Routre 1 87070 Gunn Stem 87206 GO 51149041041.814 fort to 611351 788014)8tb`szcep 87070 Ocall Blood, Fecal. IA 82274 One and Parasites nrn o.. Stool Culture } Goss. e81ro~As Throes SIE_ Nemo)* 87081 Saw UK &OLP. lta 00 glesprearyCubse.t87070 UM* Cullum. Floutinei 87896 Nuehrab• Vegnitis (VO4) Me 546 /444094910494.4401844 &KISS Vagina*. NM ;MOM C Itual 4C ;Wait KM 8148192) Grate 514IXON Polk, MA anti peg Chlawder,onoxera ggil 0 /449771 Fins OHS 941q9281184 8005 AMMO it9V1 2. NM $782102) Waives vegna tlAk 87861 Lan Bone Density Report t . ID / Suscoptibil at Additional Chargf • = Confirmation at ' I Charge = Also available wish Aptinta urine Caeeal lalormillonlCornetents Mini I . ••II 'AILS I . ..auterset sIiiii.11011WMKT metiteionfunti41}41.1;141 0.112802.61842419.11321111116811134Aillailll EFTA00287148 pLabCor .6 6 meow NV 10065 To find the nearest patient /NM service center, visit YAW 1313001110001 °r tel el» 31143092-0 LABCORP (888-522-2677). wocia.z,on rterreQu ri it er 44 E ,5'etil St Ne~ AtzsSI-NERRELL. MO CHECK Q1 AN I -I FRTIENT BILL OS C 1 MEDICARE II t INSUPANCE OXFAPt )OXFORD AETNA< )AETNA MU WO NARA( )MAGNA CARE-AV AMITE( )UNITED ALTACRE CGCtf< )CILIA NC ANC C CIESMC >CIGNA ACCRA )AARP MFDICAPI UNRF6( )OAR AETNA >METRO PLUS NPL MACMCC >HNC-MEDICARE C EMS( )EMPIRE KBE CR MAUR( )MLTAREPUD MALCIC )NALC EGU31143092 rtRAQIINYM(1.881.ffill Mq r Err URN SNarno (Last. FirR) ~nee Came' ti t invAanoe Gainer • ID. 3 5.1 4 -1a.C5 C1 ID e Gimp • 2 .72.G.Q.c . Group • Inman» ~Wee • tenement, ~roes Hems allowed Pan Reialenehlp to PrIers 'Nome Stout Ponca inelefisomhip lo Patient EMOI0Y•r NUM ; &clover Nam ;It Medicaid SUM ~an% Rear • I -arm 1:1No I t: I-8x ID Call LI Mail OlØ whrdiselwww 6anwari EGU3114:3092 ECU31143092 EGU31143092 EG1131143092 EGU31143092 EC1131143092 Sex Debt otEllith 11A5! PhyRdan's It 371044 t J LynePA(I9GiM1+B≥besi≥(29GyM... 371068 t 1 CHP14+Fe+COC/D/P1t+M9+TIBC+... 371195 t 1 FSWitiltfrog 5004.34 t Estroner LUIS, Endo Sci • • 9 085 __ .IrVLw En C1XMT•"eR wLx.1YRIREN _ 99:261 Calcaum 82310 efioNI"Oat 86140 Q884247 tilnehelM5361 80141 @ ~tug, nopolt.45.. Boat® 9..E-1‘_ ..._. 82485 ~St 82565 @ DIPOOOP19$ili) 801e2 ( i Eitick1 8267,0 Gi nit ems 0) ux., Co Finland Lit AL•tl'-E7ICALCeN:INATIeNTEST$ 006189 0071323 007401 001024 001100 005405 010342 - 480947 005199 020321 — _ _ ,___ ._ — [repeated 3 times] - _ r — _ —. Mcnont.ocose7est, Oval 85338 Be WAR LtaoProtte4 :ex: e Phenoberblel (Umber) 80184@ PhertyMin (Dilentin. ) ECM® Phosphorus e4103® Potemkin', 84132@ Prolactin 84146@ PSA 84153630103@ PSA, Free: Total Ratio' : 41r, C Nehrcntin Tim (Plytle 85610@ Fiend PTTActimed an @ PTT Achvated 85730® 006502 Rheumated Mints fact,. 864310 88592 @ Rubella AnUsodies, IgG 86762 @ Sod Rate. Westergren 85652 (Z) "944 84295 @ Testosterone. Total 84403 @ Terkeleknakroesenitren 84403E Thoophyline 80198 howitmattiProile =~4( ..3 Thmcgiste (T.) 84436 Co Toyindno R. Frio 54439E 7.pikkeSerwing Cascade =,.... Trloycorkles 844781g) Tr0000tercrece 0.4 84490(&i T.Uptake 84479® TS1I.3rd generation 84443® U6e Acid 14550 ( I udnatis a",=, en ow (;;) Vitamin 0,25-Hydroxy 6.2308@t 322744 322758 322000 303754 322750 3°3750 235010 221010 343925 341946 L. 353675 llEe 005009 028142 006068 005041 005249 006033 005025 15173 Seeroversel• __, _ ,_ _ _ Acute Hepates Panel 80074 GE Basic Melab011o Panel (8) was 071, Comp Metaboac Panel (14)60063 ,e Electrolyte panel 8005,G) Hepabc Fifteen Panel (7) soma/ Lipid Panel WeellE1 li pid pnhtt pupo. Rao an t i', WO Panel wiletel. Rain 000el (El tØ panal 04443. 00~ eoz IØ Cascade 1v..1« 004598 Ad [mina 4, o BA so 4...e Wee EIE Renal Function Panel C 13 C8Cw,11w Pit 85025 V CLICSoCew Pll 86027(a Hernidooll 85014 Ityncolotil asone) Plaledel Count asosn ) NBC Curd 85041 BD 85 WOG Count 048 V Antibody. Dikterreallbtal W8C Coss eø1 v 001016 006627 120786 007419 003139 001086 eemitemeat'iåii 001370 0023135 004515 onao 001958 001818 001032 caws 004416 001925 001453 006734 006395 GOT 84T7 X etcomplisin8 !:W47 5100098, 98600 ... , SP47. 103,11131d01$661~0) 84703 @ 8c6.8,80402*0788 84702 ® HDL Cholesterol 83718® HoniNdobin Al c 83038 @ ,--, Hep A hp 88709%LW HepE1Surlace Antibody 86706® „__, H00862592 Mogen 87340 Mi r, HCVAMifithASTe-ficalen 86803 QM) W1/02 Arthodies* 98703 @ 149.1332Mtlxdo • • NYONLY86703@ HpylohUrea Brea2, 83013 (a t) HOYSodS1031 Anti9on 87336® Iron and ISC ::.4e. X® WM 83615 (W Lithium (Eskalilh4) 80178 @I flask" 8373s ( i. 006207 006197 005215 001198 004228 070001 007336 330015 001149 001974 082345 001172 002188 001156 - 1304259 001057 003038 ‘1161950 Al 006049 001081 001107 001545 001396 164855 001123 000810 001099 1010 Hq'ETICAUp1.i:INATIrNTE5T5 — — P.130 and Rh MA NBA v PEbumn 42444R Make Phosphate's 84075lOW ALT (SORT) 84460® Amylase 82750 it...E, Anlinudear es twee@ AST (SOOT) saso(Z) on e ; 44e ,44 cm?: CE. Blkubin, Taal 82247@ BUN 84520 G 006510 144065 063824 162222 100636 180764 001321 001115 007706 1537 Cole/ton11mo fasting Celiac/ice Dale Urine hreNol Tes uo °AY VA : eY:oit/ ram= Pabonrs e Flomtai Pawns Stats O lePatlem 1:l Oui-Ptere O Non-Pant P,rn"-'1`41, totefff- NYC 1 ct Pc! rcy ,la~ (if «err from Paban4 Gty IMMs» max blryirepopaldellowlorkienterAmforg howanwriemmdmeldhlemmyenblediøeneNeefteedheldoodatird~b~n Air Yale Rdet tO Delerining 01 A28 Completion on raffle : ENDOCERY0( C ~OAT STOCII. r tmeninA ~el SOURCE' 008649 008482 038334 008540 188132 181139 180810 182949 C>38823 008144 008189 008342 6847 80039 186621 180080 180055 1812.10 183194 183160 180089 188056 88052 Aerobic Bacteria Coon t 87070 6/Ny4CA:wet 87101 evenai Cu.*. Rams I 87070 commit, any 01p 8818614 NAA 07011 BBleptattA4 Raring h ,...., FininecryCunnt 87070 Oocult Blood, Fault, IA 82274 Ova and Parasites mn ° Stool Culture 1 t, er .7%; 1/2's Th stZ it alr' Gra7",,,'47't 87081 W*willaømto9CAtatrom wino Oita Routeet 87086 NuSwatneolnes (TO) tiSientd 918P0119(9) 8•3444111~, NM MOM ct0eew8C918a1LIYA mio "Stmeas Prils. WA 87481B6) 014884bGtxutl6W Fisj ebNirvI GeMtl MytOrttla S8at• 87794(4 HSV I II 2. NM $175211(e) 74:Roncess tit» inse, ~no C.hroric Kidney Disease Repo« Codirmair Fla Paemensvi 116re «Wit 631946•Upld Cando corm wantioN~a EFTA00287149 p Isht ar, koodso%f'1ilTti$WT'i' 1t 44 E 67th St To find the nearest patientHeilim service center, visit VAWI. labcoip.com or call 888utecoftp 0388.522-267n 31143092-0 EBC31143092 e.:4G;rw v NY I0065 NYN ;11; A6255 LE QIIE 3-HERPEI L. WO ( Paberd—slogielNern00.8gtArstM0 CHECK ow nos-it-DJ Tr-Me v.Y WI - 3- PKTIEN1 SILL 05 1 3 REDICARE XI I 1 INHUME OXFHPI HIXEDID IRPISt WIPIRI SIM* CK CGCPFt MINA AC RUC C CIGIall ICIGNA HIRAI 1AEINA NH HAD CETPLI MEDD PLUS API HNIKTI IllEAL TOM I.KTAEt II.ATAIV/MT 1NI1E1 )UNITED HIII:CR1 MENAI MAGNA CARE- NY GLUM MAAR AC PUS i r O 1-9X O Cal SIMMer — MC MeA . SBC31143092 EBC31143092 [repeated 5 times] Carve, ' Ff C Insur Cartier tr, 861 4 Ci0S-511 ID • Goa* • 0272- Group • ill8;aence Marra Insurance Address Nwis ic i,nS Pam , Name el Insured Person 11;61616P le Patent netanortship to 'Mawr 6;apTol; Name Employe/ Name <v iiia c.ia State Inns es PrOAder a Workers Camp flym. ruin Sex Daleolarth Co:lector. Time Easing Cone:bon Dale M ..)05' DAY ia ma O yes mo voi ma O no 371044 l ) tyceAbflgC/111414besiatIgG/G... 371068 I I COP144Fe4C18/D/FIttligiT1184... 371175 1 1 F5E-ILUtProg 500634 1 1 Estrone, LCR5 'ndo Sri -"c '& VINPUNCTIJitt YON tAlICOO °nova 74 ' 19 Ri=1.48:.. . r TITIMMIllt-,.: 04/01T Cailn.A etAM• '--trW/ ' “1 'NV • • I ::111.1,F1 wont . GROAN • . IIIIKICEn- OR DISEASE PANELS ALPHABETICAL/COI/LUNATION TESTS A LPHABElICAUCOM8i NATIO N TES See reverse for components 006627 CaortvehtenCPPACual 86140 Mli 006189 Mcno. is Test Oust 322744 Acute Negates Panel 80074 al. 120766 faCaterflerche Rolm PP) 88141 @ 884247 HAIR 18)0Prohle. 322758 auk Melaballo Peed (8) Mae@ 007419 CarlxiMazt9re (Terre) Erma@ 007823 PhenobarbSal (Lurninee) 322000 Canp Metato9c Perot (14)93053C) 002139 CEA 82378 @ 007401 Phenytoin (Dilantie) 303754 Electrolyte Panel soosig) 001065 Cholesterol, Total 82486 (g 001024 Phosphorus 322755 Kept Ration Panel (7) 80076@ 001370 Creatirine tines@ 001180 Potassium 303756 lipid Panel =et® 007385 Digoxin (Lwow.) 80182g) 004486 Prolacdn 235010 Laid Pane %AMMO. Rae 93061C) 004515 t 84153/ Estrain 82670@ 010322 PSA 221010 LOW Panel wiTC;HOL Rat* °OM@ 004598 Feint') 82228 (g) 480947 PSA, Free: Total Ratio' 343925 Lcia Panel ieeetti Ocean 60061® 028480 FSH 844 LH =el@ 006199 Paithronthline(Pl)4NR Renal Function Panel 8OO69O 001958 ,etse s 020321 PT and PTTAceraled H EM AT OLOGY 001818 ...r‘_ Gemose, Marna 82947 .L n 006207 PTT Activated 006009 C8Cw Dill w Pit 88025 tMt` err. 006602 Rheterekei kerbs Factor 028142 CI3Cw/o Dew Pb 85027 Mt 001032 004556 Glizose, Serum 82947ism) 86,8636tel.04.mehreaaj 84703 @ 006072 APR 005058 liematoalt 86014 IMO ..— 066197 Rubella Antibodies, loG 005041 HemegIctiln 88018 in o 004416 PCG, 840aSbnt, Ova 84702 (. rn 006216 Sed Rate, Westergren 005249 Mittel Count mo m 001925 HDL Cholesterol 83718 tg,...,w, ,--... 001198 Sodium 005033 ROC Caul 88041 tone 001453 Hemoglobin Al o B3036 LLAV er... 001226 Teslosterone, Total 005025 WBC Count 85048 tr., 006734 Hap A Antibedy, Isi.4 86709 n a. I 070001 Testate:re WoseNChldren .15179 Ditlerertanote %NBC Count '°a' MI 006396 wog Surface gritted' 86706® 007396 Th00017904 ALPH.EIETICAL'CO5.181, AMU TESTS 006510 Hap EISurtace Antigen ar340 @ 006049 4/30 aid Rh 94. re... me este L4 144065 N0Vilbv/Altb Alt Vedlcalion seas @ 33°16 111"kleat Pm& 001061 Mxirrin 82° 40C) 083824 HIV•1/0/2 Antibodies' 86703® 001149 Thymcdneff.) 001107 Alkaline Phosphates° 84075® 001974 Thyroxine (7.), Free 001545 ALT 162222 iv 119-1/02M1boks • -81010867031@ 082345 7 44{,80 52wingc,444449 001396 (SGPT) 5448o Ca Amylase 62.5o all 180836 Hpykid(kee Breath 83013 @ 004122 moymt.,444 164855 Ancoudear Anuterlia" 86038 Cill len" HP7IpriSbx4Artge° 57335 C ..) 002188 Trloolothyronine (Ti) 001123 AST (SOOT) 844500 001321 Iron and MC ;t n . = @ 001166 T,Uptake 000810 Bond Fatale t n . .114: 001115 LDH 83615@ 004259 TSH, 3rd generation 001099 Welt TOW 82247 (9 361916 Lipd Cascade 6 ®IS 001057 Urk Acid 001010 BUN 86520(D 007708 Lithium (EskallO 80178 (p 003038 UnnalysiS re,:. 1016 CALICIM 82310 001537 Ma. esium 83735 s 081950 Vil.anun D, 25-Hycfroxy I ON ASi mama Urns Maim( Ms—ad— Add1848 of Pay Heeler APT if City Sum ZIP I +ow lo nmamm pqrs ibTrens Ye/ Mos do mei wan. trr matan tweet wan so 0settsies sr bap sto emet4 Istual atm. ferne0 *Mb Inn( Rater to Determinirg Necessity of ASH Completion on reverse : 67805 98309 mum emu@ solagS orlootgi $4132@ wort@ 30103 Meg 85610 =CI 85730 88431 sew 86762 85652 GP,l atine sum C) 84403 sow 1 err® C) mos 84439® =ens@ 84478 64480 84479® 84443® 865500 81003 C) 82 010 363 C ENOOCERVU C Talon C stool. UREDIRA C OTHER SOURCE 008649 008482 008334 008540 188132 188139 180810 183949 001023 008144 008189 008342 910343 910385 910374 t . ID / Sura.—pbbarly at Additional Char Cant' rotation at Additional Charge ' = Also available with Aptime urine Ciaoa utIonnmlon/Comnents /WOW SWIM Oen t 87070 Fungus Caere t 87101 00-4141Cuare.Roullne t 87070 Or Sew 87205 a 068 406 Wed, WOO gee* um NM Ph stead . 87070 t OoaM Blood Fecal. IA 82274 Ova and Parasites g Stool Comm t Thinst or neP" row•.` 87081 @ Slaw G ') tarnykracey Cam won Wee Cuba. noutnet 87044 itiSminsgrebs (VG) kdoeVagnis He (V66 S p.Z. Beacial Ninon, NM ammo Cates aC 91614494.4 Mend Cady Sepses Rele./MA melee Claidallzoo:oass. Fs MOW sm Roes Gob lestolans Seth meta 14SY I 2.1144 maw Tr/tomes wands NM. ' onset Chronic Kidney Disease Rem! CurdovascLlar Rea AsSessmenIFIN (Must order wM3619184481Cases 884247.5.1%1R UpoPralo, or kid pan Low Bone Density Report EFTA00287150 ",,Lab , Corp .I. MMXX Ctep371:0 d Maio To find the nearest patient service center, visit ,AAIA1 . labcorp.com or call 888- LAI3CORP (888-522-2677). HEAVY METALS Woodson nerr -.211 44 E Orth St Na ) ' r NY 1006S NYN 31143092 - 0 DLW31143092 ETHNICITY/RACE (CHECK ONE) Cia** q't 4HMOPĄCt ISLANQĘA is ::.. :(AMPUES9URCE 404lNE LEI VENOUS. -154404$ '.15fINGEFiSTICK RESPONSIBLE PARTY'S EMRLOYĘR'(IF ADULT) "r PARENT:GUARDIAN NAME Or MINORPAT/ENT) ,TTARENTYGUARDIANETIONE, NUMBER V libire(LIKRTTIJAI) JĘrr---ky , Sex I DatewolyBIrth 64i o CplbltionTlma r ain rl COI•C4O Dale O Yee w 0.41, I Ty O No Uri !hrsIv SEIM ea s al.alide PtrysoarVAIIIxttzeOS9Tabse Hospital Patent Swot O In-Pafient I:Out-Patti O Nan-PaW yodan's Naito Lan X OlaroolaTSIgnaoSorapters r ICO-Cht fowl in Wol at one o/ ó~alna Hi • h es — :ity tiliK • O ;Lp GL'el-.7 D Pfr ef- Mir Phca‚ta -750-40sr\l-f n /abs- ID VRt BILLING PARTY P6-1/10 55 CROAP • 6,7.2 0: SECONDARY BILLING PARTY int !s!WC anSTT - .13/ IC-Afup.A .ItiStrd/WIJ Add (ats N e o'd :nn P 6-,t.n Name cd Insure4 Person • : . ' R ance-Sp)o P.:-oy ReLeknshiT to Patent Emplzyn: NxTrA ci MKS Stet> Praexkw I ° litoikom ton; Tax A- o. ATIOTen d RW HolOor APT C.Try ZIP seastrIaboalsolabialkballa Slid b btlicAbibbIlli NOMY strarvi i os y sa cyma Yr amon I cieps br Mer mis bi in X CYR MEO% 04 L 3 PATIENT PI1 OS E 3 hEDICARE GMIN /OXFORD MDR( )EMPIRE FLUE CR UNITE( )UNITED FILTHCRE AETNA( )AETNA NON HMO DROOS( )DSDC OUT or ST BCCNY( )DS OF CENTRAL TPCIC( )TUFTS CIGNA 007625 038158 HEAVY METAL REQUEST LEAD, BLOOD (Adult) LEAD STM1DARD PROFILE (Adult) 717009 — LEAD. OWOD (PedtdrIc) ! 717033 LEAD b PROTDPCRPHYRIN (Pediatric) e s 007633 LEAD, URINE 007245 ARSENIC, BLOOD , 007039 ARSENIC EXPOSURE PROFILE, URINE I - ; 085340 CADMIUM, BLOOD 072249 CADMIUM, URINE ) lCilleM InkesullealCosinti Apply Lela to wont SpaolnTon> Only Pirtlant Control No. w 83655 an 8365 842925 M 83655 (M) 83655 84202 OM 82655570 83 VIII 82175 (RYR) 042580 g251778 IER) 82300 (RVg) 734004 82300 ri - n, 82570 '" MEDICARE ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE IABN) Reter to DeTemiinmg Necessity of ADN CompleliOn OR faint (1) a Total 24hr Vol Ht Wt .war - r ittel DZW31143092 02W31143092 AZ411143092 DZW31143092 DZW31143092 DZU31143092 HEAVY METAL REQUEST CUNT 724344 007773 007492 070813 57 mom CADMIUM STANDARD PROFILE 82232, 82 82300 0 2 os ri 2 7 I .1,41 I RY, BLOOD 83825 MERCURY, 82570 URINE 83825 82175 70 HEAVY METALS I, URINE (Pb, As, Hp) 83855 , , 8382 825 5 82300. 82570 HEAVY METALS II, URINE (Pb, As W75, Hp, Cd) 151465, 83125 83655 HEAVY METALS I, BLOOD (Pb. As. 82175, 83825 82175, 82300 W METALS II, BLOOD (Pb. As, NO, C4 ems, 83825 *MM tem8N95. 81525. 83055 COMMON ALLOY ELEMENTS, URINE sw5, 83885, axis aura OTHER TESTS TE T N. INDIVIDUAL PRO I'_. MPONENTS lllili MT: EFTA00287151