Patient Registration Form - Minidoka Memorial Hospital

MINIDOKA MEMORIAL HOSPITAL
aboratory Services
* Indicates a required field.
*Last Name
*First Name
*Initial
*Phone Number
* Date of Birth
*Address
Last 4 numbers of SSN
*City
*State
*Zip Code
*Gender
*PLEASE SELECT THE TESTS DESIRED:
$40.00
Health Fair Profile
$15.00
Total Testosterone
$10.00
P.S.A. Test (Men only)
$15.00
Glycohemoglobin (A1C
$35.00
Vitamin D-25OH
Total
We are required to have the name of your Doctor so we
can contact them in case there are values that need
PROMPT attention. Please enter the doctor's name
(FIRST and LAST) and their city and state of practice.
*Dr.'s Name
*City
*State
Yes Fax to
Doctor
No Don't Fax
to Doctor
__________________________________________________________________________________________
HEALTH FAIR RECEIPT
Please complete and tear off if you wish to seek insurance company reimbursement.
Tests performed:
Minidoka Memorial Hospital
1224 8th Street
Rupert, ID 83350
Name
Health Fair Profile - $40.00
Total Testosterone
$15.00
P.S.A. Test (Men only) $10.00
Birth Date:
Glycohemoglobin (AIC) - $15.00
"A Better Life, A Better Way"
Insurance #
Received by
NPI: 1679553531
Tax ID: 82-0291854
Diagnosis Code: 70.0
Vitamin D-25OH - $335.00
Date:
Applicable CPT codes: Chemistry Panel: Comp MET 80053, Lipid 80061,
Uric Acid: 84550, TSH: 84443, CBC:85025, PSA:G0103, Glycohemoglobin: 83036
Testosterone: 84403, Vitamin D - 250H - 82306
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