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) | | | |
| | | | | |
-----------------------
CHEMISTRY/HEMATOLOGY REQUISITION
1400 Jackson Street
Denver, Colorado 80206
Client Services 800.550.6227, option 6
clinreflabs@
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