DS9 Document EFTA00304861

atrol tic 11111 1111111111111 111 17434-0 3934515-7 UCA/110SMOUIT2 BRUCE MD IXDUKT all CR/UNIU.CLINICAL WM: 1411 N FLACLER DR STE 7100 MIEURT PALM BEACH, FL 33401 rileicm?,6115265 561-833-6116 hATEONIECIED TWO r7 Am TOOLVOLAIRS. IWesting G PM HS O Non Fasting JPEUPIN ORLIEFUNG/SUPERVISANO PHYSICIAN ANCYOR PAYORS MST BE INDICATED) ( ) 1386702876 MOSXONITZ,BRUCE U ( ) 1376970395 HARTIN,ANANDA 111 0 My Aocou t nuns= ProAdotl El Lab CardGelect :::111 n Patient Service Center location and appointment scheduling information is on the back. rp fref in • REGISTRA OTAPPUCABLE) Each sample should be labeled with nt lean two patient identifiers at time of collection. PHYS MEDIPASS AUTO # (9) ( ) CCn CIGNA ( ) ENFIR EMPIRE UN ( ) DCBS PEOMECRO ( ) GAMS OXFORD NE ( ) AM AETNA ( ) UNTO UNITED HE ( ) COLOR ;OLDEN RU ADINTL PHYS.: Dr. OiNaNYMCIAN NAVE LOS PROVIDER tax Results to d Gamma arts ADORESS: 'owlet CITY PATIENT SOCIAL SECUNTY I/ N DATE OF BIRTH I I ROOM • LAB RIPERENCI• YEAR I I OFFICE/MENTOS PATIENT PHONE • ) SD PAINT NAME OF INSLPED/IFSV0NSBLE PAM PAST. RASE OS:VW- FOROBIANFATENT I ' , t I ; I I I I I SERENTS/REETADORESSIORINSUREDRESPONSIBLEPARTO APT' KEY/ CITY I I 1 , 1 ; 1 1 i i l l I I nEtATIONSHIPTO INSURED: 0 NAP 0 DITIVOINT STATE ZIP PRIMARY INSURANCE CO. NAME I 1 1 1 1 1 eismriaft /INSURED ID NO.0 • I I I I MSURANCE A STATE_ ZIP Medicare Limited Coverage Tests L i ; STATE I I ZIP 411= May not to covered to the reported diagnosis. F • Has pros:Axe frequency ides for covorego. de .-. A leSt or service corlomme with research /experiment kit B - Has togs diagnosis aro hear onCY-lolal CO"Ine FnItath'IS when e A ir Wean ( )0302946 CP 302966 ( ) 303644 CP 303644 ( ) 307978 CP 307978 0338742 ( ) 223 ( ) 234 ( ) 823 ( ) 5509 ( ) 243 AHYLASE ( ) ( ) 249 ANA IF* U/RFL IFA ( )0 ( ) 822 AST ( )8 ( ) 10165 BASIC MET PHL ( ) ( ) 852 BETA 2 NICROGLOBULIN( re t ) 287 BILIROBIN, TOTAL ( )8 ( )8 4698 CA 19-9 t >8 ( re 29256 CA125 ( )8 ( >8 303 CALCIUM ( ) ( )8 6399 CBC (DIFF/PLT) ( ) ( )8 1759 COC(H/H BBC NBC PLT)( ) ( )8 478 CEA ( )8 334 muumuu:rum ( ) 374 CV, TOTAL ( ) 10231 COMP META PHL ) 167' CORTISOL, TOTAL 4 )8 10124 HS CRP ( ) 859 13, TOTAL ( ) 375 CREATININE ( ) 549 IMBUNOFIXATIOR,S£RUM ( )8 867 14 (THYROXINE) i ( y" 4420 CRP ( )8 571 IRON, TOTAL ( )8 866 14, FREE Cl' 338742 ) ALBUMIN ( ) ALKALINE PNOSANATASE( ) ALT ( ) AMMONIA (P) ( ) 10108 CULTURE, STOOL 11/RFL ( )8 7573 8 8293 DIRECT LDL ( ) 593 34392 ELECTROLYTE PANEL ( )8 7600 4021 ESTRADIOL ( ) 8593 8 457 FERRITIN ( ) 34127 470 FSH ( ) 659 483 GLUCOSE ( ) 21130 498 HASA8 U/RFL CONE ( )8 622 35645 NO RNA, OH PCR ( ) 636 608 HDL CHOLESTEROL 18 509 NEMATOCRIT 510 HEMOGLOBIN 496 HEMOGLOBIN A1C 512 NEP A IBM 4948 HEP B CORE IGM AD 8472 REP C AD N/REFL NCV 10306 HEP PHL ACUTE U/REFL ( )8 10256 HEPATIC FUNCTION PH ( ) 41431 NIU1/2 86/00,4 N/RFL 31789 IMUEMUTEINE ( >0 IRON, TOTAL, AND IBE.fr4r 873 LD ( )0 896 LIPID PANEL ( )8 899 LYME DIS IWO BLOT ( ) 294 RAINED ICS AHD IGO ( ) 905 M.PNEUMO. AB (1CC) t ) 6448 M.PNEUBO. AB (IGN) ( ) 7909 MAGNESIUM 5463 MERCURY, BLOOD J.48 17306 PET SODIUM CITRATE...A-1 927 733 POTASSIUM SOURCE: 8847 PHD TINE WITH INK ( ) 91664 C DIFF TOXIN IMRE 747 PROTEIN ELECTRO. ( ) 4475 CAMPY CULTURE 754 PROTEIN, TOTAL, (5) ( ) 394 5363 PSA, TOTAL 395 8837 PIN, INTACT 4. CAL. ( ) 11290 763 P11, ACTIVATED ( ) 11293 4418 RHEUMATOID FACTORS ( ) 681 809 SED RATE BY no NEST ( ) 10019 861 T3 UPTAKE ) 30264 TESTOSTERONE,MALE TRIGLYCERIDES TSH UREA NITROGEN (DU URIC ACID URINALYSIS MACRO URINALYSIS REFLEX. URINALYSIS, CIMPL VII 8,25-ini,Toint VITAMIN 012 CULTURE, THROAT CULTURE, UR ROM FECAL InnunocnEn FECAL INDUNOCHEM OVA AND PARASITE SAIM/SHIG, COLIMA SHISA TOM, EIA XBIALTESTRherSTiNCUDECOMilthiEMEUNAMEANDORDERCOW) Reflex tests are performed at an additional charge. WNW, CUNICAL INFORIAATION: CEA &green flequkad for PA, NY,NJ &WV% TOTALTESTSI I ORDERED L_ Many payers kinciading ?dedicate and Medicaid) have medical wecessity requirements. Yes shoild only order those tests welch are medically necessary tat the diagnosis and treatMett aline patient • - * Additional charge for ID/Susceptibility studies. 17436 3936515 17436 3936515 REOBKTP 17436 3936515 17436 393651S .:,a4‘Wilkays.cABaegNVIESTX"OhohteftdRichmaecrearNts& —1-tisaa"k-ale--Itti---Tresnyorsaum EFTA00304861