1370 Valley Vista Dr., #145 AFFIX LABEL HERE Diamond Bar, CA 91765

1370 Valley Vista Dr., #145 AFFIX LABEL HERE Diamond Bar, CA 91765

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