MINIDOKA MEMORIAL HOSPITAL

MINIDOKA MEMORIAL HOSPITAL
aboratory Services
* Indicates a required field.
*Last Name
*First Name
*Initial
*Phone Number
* Date of Birth
Last 4 numbers of SSN
*Address
*City
*State
*Gender
Fax to Doctor
*PLEASE SELECT THE TESTS DESIRED:
$35.00
Chemistry Profile
$10.00
Complete Blood Count
$10.00
P.S.A. Test (Men only)
$15.00
Glycohemoglobin (A1C
*Zip Code
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
Total
*State
To enable more accurate interpretation of your Health Fair results, please answer the followin questions. The questionnair is optional,
but the answers will help your Healthcare provider several days from now to know what factors may be contributing to your results
today.
How do you feel today compared to the way you usually feel?
Same
Better
Worse
What was your main course at dinner last night?
Did you get sore muscles this week from strenuous exercise or a fall?
Are you on a regular high protein diet?
Vitamins with Iron?
Yes
No
No
Do you take extra Potassium?
Do you take Thyroid medicine?
No
Medicine to control your sugar?
Do you take antacids?
Yes
Yes
Yes
Yes
No
Yes
No
No
Daily
Weekly
Occassionaly
Rarely
Never
After your Healthcare provider has received your Health Fair results, you may request a copy of this form faxed to them to assist with your care.
__________________________________________________________________________________________
HEALTH FAIR RECEIPT
Tests performed:
Please complete and tear off if you wish to seek insurance company reimbursement.
CBC - $10.00
Name
Minidoka Memorial Hospital
1224 8th Street
Rupert, ID 83350
"A Better Life, A Better Way"
NPI: 1679553531
Tax ID: 82-0291854
Diagnosis code: V 70.5
PSA $10.00
Glycohemoglobin
$15.00
Chemistry Panel w/TSH &
Iron $35.00
Birth Date:
Insurance #
Received by
Date:
Applicable CPT codes: Chemistry Panel: Basic Met: 80048, Hepatic: 80076, Lipid: 80061, Magnesium: 83735,
Phosphorus: 84100, LDH: 83615, Uric Acid: 84550, Iron: 83540, TSH: 84443.
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