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    Lab Req 11

    Uploaded by

    karthick T
    This laboratory requisition form provides information about a patient named A.T. Williams who is requesting various lab tests. It includes the patient's demographic and insurance details, ordering provider information, diagnoses, the specific lab tests being ordered, and signatures authorizing the services and release of information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Lab Req 11

    Uploaded by

    karthick T
    63 views2 pages
    This laboratory requisition form provides information about a patient named A.T. Williams who is requesting various lab tests. It includes the patient's demographic and insurance details, ordering provider information, diagnoses, the specific lab tests being ordered, and signatures authorizing the services and release of information.

    Original Title

    Lab-Req-11

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This laboratory requisition form provides information about a patient named A.T. Williams who is requesting various lab tests. It includes the patient's demographic and insurance details, ordering provider information, diagnoses, the specific lab tests being ordered, and signatures authorizing the services and release of information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    63 views2 pages

    Lab Req 11

    Uploaded by

    karthick T
    This laboratory requisition form provides information about a patient named A.T. Williams who is requesting various lab tests. It includes the patient's demographic and insurance details, ordering provider information, diagnoses, the specific lab tests being ordered, and signatures authorizing the services and release of information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Laboratory Requisition Form

    718 Teaneck Road Requisition#:2480000056


    Teaneck, NJ - 07666

    Patient Information
    Name : A T. Williams MRN Number : M000001501
    Gender/DOB : Male | 01/01/1990 | 32Y Visit Date/Time : 06/04/2022 7:45 PM
    Address : 3000 OLD CANTON RD, Jackson, MS - Episode Number : A000000002282
    39216
    Email : balachandar.p@tvsnext.io Cell : (234) 324-3243

    Insurance Information
    Relationship : Father Relationship : Uncle
    Subscriber Karthick Davis Subscriber Name : Karthick Testeight
    Name : Secondary Name : AARP - Medigap Plan
    Primary AARP - Medigap Plan Address : 423 East 23rd Street, New York,
    Name : New York - 10010
    Address : 423 East 23rd Street, New York, New Policy Number : 8764654738383
    York - 10010
    Policy 9876543210
    Number :

    Worker’s Date of Injury :


    Comp :

    Ordering Provider
    Name : Marshall D. Webster Facility Name : HNMC Practice Management
    NPI : 1003000415 Facility Address : 718 Teaneck Road,Teaneck,New
    Jersey-07666
    Phone : (655) 645-4323

    Diagnosis Code
    ICD Code Description ICD Code Description
    C85.10 Unspecified B-cell lymphoma, E11.9 Type 2 diabetes mellitus without
    unspecified site complications
    E10.9 Type 1 diabetes mellitus without
    complications

    Order Information
    Order Code Order Description Specimen Fasting Collection Date/Time
    Requirement
    CBD CBC w/Differential N N 06/20/2022 9:08 AM
    NH3 Ammonia N N 06/20/2022 12:00 PM
    BC5 Blood Culture - 2nd site Y N 06/21/2022 5:27 PM
    TP Total Protein (Blood) Y N 06/21/2022 5:27 PM
    CBC Complete Blood Count Y N 06/21/2022 5:27 PM

    Guarantor Information
    Relationship : Self
    Name : A T. Williams
    Gender/DOB : Male | 01/01/1990

    MR#: M000001501 Page 1 of 2 printed on 06/23/2022

    Episode#: A000000002282
    Laboratory Requisition Form
    718 Teaneck Road Requisition#:2480000056
    Teaneck, NJ - 07666

    Address : 3000 OLD CANTON RD, Jackson, Emergency Contact Information

    Mississippi - 39216 Relationship : Uncle


    Cell/Phone : (234) 324-3243 Name : Emergency C. Lab
    Address : 3333 Broadway, New York, New York
    - 10031
    Cell/Phone : (876) 543-2908

    Authorization - Please sign and Date


    I hereby authorize the release of medical information related to the services described hereon and authorize
    payment directly to Holy Name. I agree to assume responsibility for payment of charges for laboraatory services
    that are not covered by my healthcare insurer.

    Patient Date:
    Signature :

    Provider Date:
    Signature :

    MR#: M000001501 Page 2 of 2 printed on 06/23/2022

    Episode#: A000000002282

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