Patient Last, First Name, M



FACILITY / CLIENT INFORMATION [PLEASE PRINT] | |

|Facility Name       |Telephone       |Ordering Physician |

| | |      |

|Street       |Fax #1       | |

|City       |State    |Zip       |Fax #2       |UPIN       |NPI #       |

| |

|PATIENT INFORMATION [PLEASE PRINT] |Patient Diagnosis:       |ICD-9 Code:       |

|Patient: First Name       |Last Name       |Responsible Party (if other than patient)       |

|Date of Birth       |MM/dd/yyyy | Male Female |Relationship to Patient       |

|Street Address       |Street Address       |

|City       |State    |Zip       |City       |State    |Zip       |

|Telephone       |Telephone       |

|Bill to: | Client | Up front payment (check / credit card) | Patient | Medicare | CO Medicaid |

|**IF BILLING MEDICARE, or CO MEDICAID, PLEASE INCLUDE PHOTO COPY OF FRONT & BACK OF CARD or provide information below** |

|CARRIER NAME |BILLING ADDRESS |ID NUMBER |GROUP NUMBER |

|      |Address      |      |      |

| |City       | | |

| |State       ZIP       | | |

|PHONE NUMBER | |SUBSCRIBER |SUBSCRIBER DOB |

|      | |      |      |

|I request payment of medical benefits for the laboratory services directly to ADx Labs NJH. I authorize ADx Labs NJH to release to any medical carrier providing medical |

|benefits to me and any health plan of which I am a member, any medical or other information needed for claim or payment purposes. I acknowledge I am responsible for any |

|services not covered by my medical carrier. |

|Patient Signature: |Date: |

| |

|Specimen Source: Serum Plasma Blood Urine Other:       |Collect Date:       |Collect Time:       |

| Raw Specimen OR Culture Medium: |Submitter Specimen #:       |

|Form completed by [Print name]:       |Date       |Telephone       |

|CHEMISTRY PANELS |CHEMISTRY TESTS |URINALYSIS |

| BMPX |Basic metabolic panel | ALBX |Albumin | Random 24 Hr. Collection |

| CMPX |Comprehensive metabolic panel | ALKX |Alkaline phosphatase | AUA |Urinalysis |

| HFPX |Hepatic function panel | AAMYL |Amylase | UHCG |Urine beta hCG |

| LIPANX |Lipid panel | ASTX |Aspartate transaminase | UCAX |Urine calcium |

| ELPLX |Electrolyte panel | BUNX |Urea nitrogen | UCLX |Urine chloride |

| RNFPX |Renal function panel | CAX |Calcium | UCREAX |Urine creatinine |

| | | CO2X |Carbon dioxide | UDRGS |Urine drug abuse screen |

| | | CLX |Chloride | UKX |Urine potassium |

| | | CHOLX |Cholesterol | UPHOX |Urine phosphorus |

|HEMATOLOGY | CPKX |Creatine phosphokinase | UNAX |Urine sodium |

| HCBC |CBC with automated diff | NJCKMB |CPKMB quantitation | MTPX |Urine total protein |

| CEOS |Circulating eosinophils | CRETX |Creatinine | UUNX |Urine urea nitrogen |

| ESR |Erythrocyte sedimentation rate | DBILIX |Direct bilirubin | UURX |Urine uric acid |

| ARETIC |Reticulocytes | FEX |Iron | | |

| SNAS |Nasal eosinophils | FEIBX |Iron & iron binding | | |

| SSPU |Sputum eosinophils | FERRIX |Ferritin | | |

| | | GGTX |Gamma glutamyl transferase | | |

| | | GLUCX |Glucose, random |MISCELLANEOUS TESTING |

| | | GLUFX |Glucose, fasting | FOLICX |Folate/Folic Acid |

|COAGULATION | HDLCX |HDL cholesterol | PTHCAX |Intact Parathyroid Hormone + Calcium |

| APTT |Act. partial thromboplastin time | HBA1CX |Hemoglobin A1C | VTB12X |Vitamin B12 |

| NJDIME |D-dimer | LDHX |Lactate dehydrogenase | | |

| PTIME |Prothrombin time/INR | MGX |Magnesium | | |

| | | PHOSX |Phosphorus |COMMENTS: |

| | | | |      |

| | | KX |Potassium | |

| | | NAX |Sodium | |

|THYROID | TBILIX |Total bilirubin | |

| TSHX |Thyroid stimulating hormone | TPX |Total protein | |

| FET4X |Free thyroxine (free T4) | TRIGX |Triglycerides | |

| TUPTX |T3-Uptake | NJTROP |Troponin | |

| TT4X |Total T4 | URICX |Uric acid | |

| THYPX |Thyroid Panel | | | |

| |(Total T4, T3 Uptake, FTI) | | | |

| | | | | |

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CHEMISTRY/HEMATOLOGY REQUISITION

1400 Jackson Street

Denver, Colorado 80206

Client Services 800.550.6227, option 6

clinreflabs@

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