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THIN PREP THIN PREP w/REFLEX HPV HI GHPV THIN PREP w/HPV HIGH RISK FPO FOR AFFIXED LABEL GYN GYN NGYN CYTOLOGY urine E C N A R U S N I Patient Information General Test Requisition Last Name First Name MI Male Female D.O.B. / / Address (Street) City City State State State Call results to: (____) ______________ Fax results to: (____) ______________ Zip Zip Apt # Floor Room# Telephone # Client Chart/Pt. ID# Responsible Party/Subscriber Social Security # ACCT: Billing information* Bill Patient Bill Client Bill Medicare Bill Medicaid Bill Insurance SELF SPOUSE CHILD OTHER ) Insurance Company Name Subscriber Member # Location Group # Telephone # DIAGNOSIS/SIGNS SYMPTOM IN ICD-10 FORMAT (Highest Specificity) Medicaid # 24-HOUR URINE VOLUME IN ML FASTING YES NO Insurance Address Physician’s Provider I have read the ABN on the reverse. If Medicare denies payment, I agree to pay for the identified test(s). Patient’s Signature Date S S S E T Y L O R T C E L E 0 1 Na, K, Cl, CO Na, K, Cl, Co , Glu, BUN, Cr, Ca CO Alb, TBil, DBil, AP, AST, ALT, TP Trig, Chol, HDL, LDL calc, VLDL calc, Ratios 2 2 2 11 BASIC METABOLIC SS 12 COMPREHENSIVE METABOLIC SS 27 HEPATIC FUNCTION SS S S E L I F O R P D I P I L 8 3 Na,K,CI, Glu, B ,Cr,Ca,TP, Alb, TBil AP, AST, ALT, UN A.M.A. PANELS CUSTOM PROFILES/ADDITIONAL TESTS: T S S : 1 D I O R Y H T 9 2 T S S : E L I F O R P D I O R Y H T 2 6 39 B12 + FOLATE DEFICIENCY: SST Y G 3 E C N A R E L O T E S O C U L G 24 V L , S S : S I T I R H T R A 1 3 T4, T3Uptake, FTI, ,T3p, FTI, FT4, B12, FOL hrs CBC, ANA, ASO, CRP, RF, ESR, URIC ACID TSH T4, T3, TSH GLU, HGB A1C GTT2 V L , Y G : E L I F O R P C I T E B A I D 2 P20 PROFILE: S S 2254 V L , S S A I M E N A HEPATITIS PANEL: S S L A T O T & E E R F A S P 3 2 1 P CBC,B12,FOLATE,IRON/TIBC/UIBC/SAT%,RETIC HBsAG, HBsAB, HBcAB, Hav, HCV S842 S842 PLACK Black/Yellow (Medicare) NMR Black/Yellow OTHER PANELS S S 7 0 0 2 V L CF60 SS/RE 8 4 1 E R X987 S S 1076 A U 5 2 1 1 S S 1798 S S 5 8 1 S S 5 1 1 S S 3 6 1 S S 9 3 1 S S 6 1 1 177G V L 9 1 1 S S S S 7 4 1 S S 2 3 2 A S S 9 1 3 S S 0 2 3 CRP CARDIO (HS) Cystic Fibrosis, 60 mut DIGOXIN DILANTIN DNA DS, IgG IFA DRUG SCREEN 10 PANEL/CONF EBV Evaluation ESTRADIOL FERRITIN FOLATE FSH GGT (GGTP) GLUCOSE fasting GLYCO Hgb A1C GLYCOMARK HCG Beta sub Quant Hep A Total Ab Hep B Surface Ag Hep B Surf Ab S S 1 2 3 S S 8 1 3 Hep B Core Ab Hep B Core IgM S S 1 0 7 A S S 8 0 1 S S 657 V L 747 S S 3 0 3 S S 0985 S S G Y P H S S 7 7 6 V L BLPB S S 3 2 1 S S 7 8 9 0 S S 0 4 1 S S 9 6 3 3 S S S157 S S X628 S S X177 S S 5 2 1 S S 4 4 9 A U 2 1 2 S S 5 6 7 E R X597 S S 7 2 1 Hep C Ab HDL Cholesterol HSV I IgG S S 658 HSV II IgG Scr (MONO) HIV-1/2 AB H. PYLORI Ab IgG S S 7110 H. PYLORI Ab IgM HOMOCYSTEINE LEAD (NOT NY) LDH LDL Direct LH LIPASE LIPOPROTEIN-A LITHIUM MAGNESIUM MEASLES Ab IgG ( MICROALBUMIN MUMPS Ab IgG PHENOBARBITAL PHOSPHORUS HEMOGLOBIN ELECTROPH. HETEROPHILE LYME IGG/IGM w/ref W.B. Rubeola) 655 PARATHYROID Horm. Intact SS S S 4 3 1 S S 4 3 1 A S S 1 8 1 S S 1 3 1 T S S 603 S S 3 2 1 S S S 6 9 1 L B 6 3 0 L B 7 3 0 V L 7 4 2 S S 4 0 3 S S 1 1 3 S S 5 0 3 V L 6 4 2 V L 6 5 0 S S 3 3 1 S S 2 5 2 S S 5 4 1 S S 0 8 9 S S 4 4 1 E R X621 S S 7 8 1 POTASSIUM PROGESTERONE PROLACTIN PROTEIN Total PROT. ELECT. PH./SPEP PSA FREE PSA PT/INR PTT RETICULOCYTE cnt RF (Rheumatoid) RUBELLA IgG Ab RPR SED RATE (ESR) SICKLE Cell Monitoring SODIUM T4, FREE T3 UPTAKE T3, TOTAL T4, TOTAL TEGRETOL (Carbarm) TESTOSTERONE, Total S S S236 TESTOSTERONE, Free & Total E T A D E M I T AM PM SPECIMEN COLLECTION STAT MEDICARE ADVANCE BENEFICIARY NOTICE (ABN) ICD 10 DIAGNOSIS CODE(S) FOR TESTS ORDERED 1901 East Linden Ave, Suite 4, Linden, NJ 07036 Tel: 908-474-1004 • Fax: 908-474-0032 www.accureference.com x TESTS E R / V L S665 S S 7 9 1 S S 1 0 1 S S 2 0 1 S S 6 0 1 S S 5 0 1 S S S S 1 0 3 0 S S S 2 0 3 S S 7 0 1 S S 9 2 1 S S 3 1 1 S S 6 3 1 S S 4 8 6 S S 8 9 6 S S CA19 S S S S 3 0 1 V L 0 2 S S 3 8 3 S S 5 3 1 S S S S 9 0 1 712 ABO group & RH AFP Tumor marker ALBUMIN ALK. PHOSPHATASE ALT (SGPT) AMYLASE ANA Screen/w reflex 1365 APOLIPOPROTEIN B ASO (Quant) AST (SGOT) BILIRUBIN, Total BILIRUBIN, Direct V L 0712 BNP BUN S S S204 BNP-NT pro Screen CA 125 CA 15.3 CA19 CA27 CALCIUM CBC, DIFF, PLT CEA CHLORIDE CHOLESTEROL CK-MB S S 0 1 1 CPK CA27 S S B I R I S S P A V SS C U URCS M R I F F A P B VPAT IRON/TIBC VAP URINE CULTURE w/sens. VAGINAL PATHOGENS S S 2 3 1 S S 6N 4 1 S S 7 3 1 A U 0 3 0 E R X658 S S 2 0 4 S S S 2 6 1 995 L F BFCG W S GENC T S STCU W S THAB W S WOUC T S 0 0 1 S A U APT/ CGU T S CDIF T S 0 7 7 TRIGLYCERIDES S S Q518 THYROGLOBULIN AB S S 1078 THYROID PEROXIDASE AB (TPO) TSH URIC ACID URINALYSIS VALPROIC ACID DEPAKENE VARICELLA Ab IGG VITAMIN B12 CULT. BODY FLUID CULTURE GENITAL CULTURE STOOL CULT. THROAT (Strep A, B) CULTURE WOUND O & P STOOL GC & C C.DIFF A&B/AG OCCULT BLOOD SS Q099 AFP Maternal Quad Screen VITAMIN D-25 HYDROXY HLAMYDIA LAB USE ONLY S S 2 1 1 S S 6 3 5 1 CREATININE CRP QUANT S/GY S GLYM LMP __ __/__ ___/_ ____ __ _ _ CX VG EXCEL PRINT PACK 732.364.7736
