1370 Valley Vista Dr., #145 Diamond Bar, CA 91765 Tel. (909) 861-2000 Fax (909) 861-2008 AFFIX LABEL HERE BIOSCIENCES STAT FASTING BILLING INFORMATION PATIENT INFORMATION PATIENT’S LAST NAME FIRST SOCIAL SECURITY NO. SEX M AGE M.I. MEDICARE APT. / SPACE ZIP PHYSICIAN’S SIGNATURE POLICY NO. MEDICARE NO. DIAGNOSTIC PANELS - COMPONENTS LISTED ON BACK S Lipid Panel (Coronary) Anemia Panel S S,L S Liver Panel Hypothyroid Panel S S,L Obstetric Panel Arthritic Panel Lupus Panel S Renal Function Panel S S,L S Prenatal Profile Arthritic Profile S Amylase ANA - SLE Latex ASO Vitamin B-12 CK, Total CK, MB ESR Glucose, Fasting HDL Heterophil (INF, Mono) Iron/TIBC Lead (PED) Lipase Pregnancy (S) Pregnancy (U) Protime PTT RA Latex Retic Ct Rubella Antibody Sickle Cell Uric Acid ENDOCRINOLOGY PTH Intact T3 Total T3 Uptake Free T3 T4 Total Free T4 TSH (Ultra S) Hgb A1C Thyriod Profile II S HORMONE S S S S S S L GY S S S L S S U B B S L S L S S S S S S MEDICAL NO. ICD-9 CODES HEPATITIS (cont.) Estradiol Estriol Estrogen FSH LH Prolactin Testosterone Total Testosterone Free S S S S S S S S CANCER MARKERS AFP CA 15-3 CA 19-9 CA 27-29 CA 125 CEA PSA, Total PSA, Total & Free S S S S S S S S COMMUNICABLE DISEASE STS (RPR) HIV Chlamydia, DNA Chlamydia (U), DNA Gonorrhea, DNA Gonorrhea (U), DNA Herpes I (IgG) Herpes II (IgG) Herpes I & II (IgM) HEPATITIS HAV Ab (IgM) HAV Ab (Total) HBc Ab (IgM) S S M4 U M4 U S S S HBc Ab (Total) HBe Ab HBe Ag HBs Ab HBs Ag HCV Ab GYN CYTOLOGY Thinprep Pap with Imaging Surepath Pap Conventional Pap S,L HPV Only S Liquid Based Pap & HPV HPV Reflex Test (HR) with (+) ASC-US S,L S SOURCE: Cervix / Endocervix Vaginal LMP: S,L Routine exam Hormone Replacement / Estrogen Oral contraceptives Postcoital Bleeding Pregnant wks Postmenopausal S Postpartum wks Hysterectomy (Total or Partial) S Abnormal bleeding Pelvic Radiation S Previous Abnormal Gyn: ASC-US / LSIL / HSIL / HPV / Malignancy / Prior Biopsy S Explain: S Tissue Pathology S THERAPEUTIC DRUG Cyclosporin Digoxin Dilantin Depakene FK (506) / Tacrolimu Lithium Phenobarbital Theophylline Vacomycin (TR) Vacomycin (PK) MICROBIOLOGY SOURCE AFB Smear AFB Culture Fungus Culture G.C. Culture GP A Strep Screen GP B Strep Screen Gram Stain Routine Culture Throat Culture Urine Culture Vaginal Culture Specimen Anatomic Site: L S S S L S S S S S Clinical History (size, duration, impression): 1. 2. 3. 4. 5. Non-Gyn Cytology Specimen Source (urine, sputum, FNA, etc.): Clinical History / Impression: 1. 2. Tissue pathology and non-gyn cytology may require special studies, special stains or markers as deemed appropriate for proper diagnostic evaluation by pathologist. These additional tests may result in additional charges. MICROBIOLOGY & PARASITOLOGY GC & CHLAM AMPLIFIED Swab Urine ROUTINE CULTURE S S S Source: ADDITIONAL TESTS / COMMENTS - PLEASE CIRCLE DESIRED PROFILE(S) TEST NUMBER(S) For patient of any payor (including Medicare and Medicaid), order only those tests which are medically necessary for the diagnosis and treatment of the patient. Patient will be responsible for all charges or deductibles as allowed, not paid by insurances. S S L CHDP GROUP NO. Did the patient sign the ABN / Is ABN attached? Limited coverage tests require medical necessity ICD code or ABN. INDIVIDUAL TESTS INSURANCE ADDRESS PATIENT ADDRESS Acute Hepatitis Panel General Health Panel Basic Metabolic Panel Comp. Metabolic Panel Electrolyte Panel Thyriod Profile DOCTOR/CLIENT MEDICAL INSURANCE COMPANY BIRTHDATE PHONE STATE BILL TO: PATIENT F ALTERNATE PATIENT I.D. CITY TIME COLLECTED DATE COLLECTED Ova & Parasites Occult Blood BD Affirm (ATTS tube) Wet Mount CMS / MEDICARE APPROVED PROFILES WITH COMPONENTS GENERAL HEALTH PANEL BASIC METABOLIC PANEL RENAL FUNCTION PANEL CALCIUM COMPREHENSIVE METABOLIC PANEL (CMP) ALBUMIN CARBON DIOXIDE CBC CALCIUM CHLORIDE TSH CARBON DIOXIDE (BICARBONATE) CHLORIDE CREATININE CREATININE GLUCOSE ACUTE HEPATITIS PANEL POTASSIUM SODIUM GLUCOSE HEPATITIS A ANTIBODY, IgM ANTIBODY HEP B CORE ANTIBODY, IgM ANTIBODY HEP B SURFACE ANTIGEN HEP C ANTIBODY UREA NITROGEN (BUN) BUN / CREATININE RATIO (CALC) ANION GAP (CALC) PHOSPHORUS INORGANIC (PHOSPHATE) POTASSIUM SODIUM BUN / CREATININE RATIO (CALC) UREA NITROGEN (BUN) ANION GAP (CALC) HEPATIC FUNCTION PANEL ALBUMIN COMPREHENSIVE METABOLIC PANEL BILIRUBIN TOTAL ALBUMIN BILIRUBIN TOTAL CALCIUM CARBON DIOXIDE (BICARBONATE) CHLORIDE CREATININE GLUCOSE PHOSPHATASE, ALKALINE POTASSIUM PROTEIN, TOTAL SODIUM TRANSPERASE, ALANINE AMINO (ALT)(SGPT) TRANSFERASE, ASPARTATE AMINO (AST)(SGOT) UREA NITROGEN (BUN) BUN / CREATININE RATIO (CALC) ALB. / GLOB. RATIO (CALC) ANION GAP (CALC) BILIRUBIN DIRECT BILIRUBIN INDIRECT (CALC) PHOSPHATASE, ALKALINE PROTEIN, TOTAL TRANSPERASE, ALANINE AMINO (ALT)(SGPT) TRANSFERASE, ASPARTATE AMINO (AST)(SGOT) ALB. / GLOB. RATIO (CALC) LIPID PANEL HDL CHOLESTEROL TRIGLYCERIDES LDL (CALC) VLDL (CALC) CHOL / HDL RISK RATIO (CALC) ELECTROLYTE PANEL CHLORIDE CARBON DIOXIDE (BICARBONATE) POTASSIUM SODIUM ANION GAP (CALC) OBSTETRIC PANEL CBC w/PLATELET COUNT & DIFFERENTIAL ABO GROUP & RH TYPE ANTIBODY SCREEN RUBELLA AB IGG RPR HEP B SURFACE ANTIGEN ADDITIONAL PROFILES ARTHRITIC PANEL ANEMIA PANEL CBC w/PLATELET COUNT & DIFFERENTIAL FERRITIN FOLIC ACID IRON & TIBC VIT B-12 RF CRP ASO ANA PHOSPHORUS CALCIUM URIC ACID ALK. PHOS. SED RATE ARTHRITIC PROFILE RA ANA ESR URIC ACID HYPOTHYROID PANEL T3 U T4 TOTAL T7 CALC. TSH LUPUS PANEL ANA EIA THYROID PROFILE ANTI-DNA ANTI-ENA (INCLUDES ANTI SM & ANTI RNP) ANTI-MITOCHONDRIAL ANTIBODY PRENATAL PROFILE COMPLEMENT C4 ABO PARIETAL CELL ANTIBODY, IFA RH SMOOTH MUSCLE ANTIBODY RPR ANTI-SSA RUBELLA ANTI-SSB CBC/PL TT THYROID PEROXIDASE ANTIBODY UA LEGEND T UPTAKE T4 FTI THYROID PROFILE II T UPTAKE T4 FTI TSH ALL MICROBIOLOGY CULTURES B FS - FROZEN SERUM GN - GREEN TOP L GY - GREY TOP Test: HIV 1,2 (Antibody) - HV reflexes to WB if HIV is positive U Test: RPR - RPR reflexes to Serodia-TP if RPR is reactive - LAVENDER TOP R - RED TOP - BLUE TOP Microbiology Culture reflexes to Sensitivity if indicated. Reflex tests are performed at an additional charge. S - SERUM SEPARATOR TUBE - RANDOM URINE REFLEXES (IF REQUESTED) Revised 7/4/13