LABORATORY REQUISITION

Name/Last 367 Athens Highway Bldg #100 Loganville, Ga 30052 Chris Ibikunle, MD FCAS SSN: Medical Director BILLING INFORMATION* Client Bill___________ Medicare___________ Insurance__________ Ordering Policy or Medicare#: __________________ __________________ Physican: Group #: _____________________ Secondary____________________ Diagnosis: Patient Address: __________________________________________________________ Collection Date: Fasting Yes ATTACH COPY OF CARDS - SEE INSTRUCTIONS

Patient Information First: Phone:

DOB:

Male

Female

Acct. Code: WRITE HERE OR CHECK BOX(S) BELOW

No

AM Time: PM Collected By: User ID: _______________________________

NOTE TO PHYSICIANS: When Ordering tests for which Medicare reimbursement will be sough, Physicians (or other individuals authorized by law to order test) sould order tests that are medically necessary for the diagnosis and treatment of the patient, and not for screening.

Bolded tests / anels have limited coverage policies by Medicare and require appropriate diagnosis for reimbursement DIAGNOSES oAbdominal Pain oCHF oHyperglycemia oNeuropathy oAtrial Fibrillation oCough oHypertension oPneumonia oAnemia NOS oDM I oHyperthyroidism oProstate CA oArrythmia oDM II oHypothyroidism oTachycardia oCAD oDyspnea oHypercholesterolemia oUTI oChest Pain oFatigue oMedication effect oWeidgt loss AMA Panels oHEPATIC (LIVER) PANEL CHEM 6 oBMP CHEM 8 oCMP CHEM 14 oELECTROLYTES ELECT oHEPATITIS PANEL HEPPAN oLIPID PANEL LIPID oRENAL PANEL RENAL SEROLOGY oANA ANA oH. PYLORI HELPYL oMONO-HETEROPHILE HETERO oRHEUMATOID FACTOR RHF oRPR RPR oRUBELLA RUB oSYPHILLIS IGM AB SYPHM MICROBIOLOGY oUrine Cult. (sens.rflx) UR oStrep Grp A - Rapid STREPA oThroat Culture THR oINFLUENZA A& B FLU oCHLAM/GC AMP . DNA CTGC oOther - Source _______________________ INDIVIDUAL TEST oCBC CBC oHCG, SERUM HCG oCMP CHEM 14 oHCG, URINE HCG-U oLIPID PANEL LIPID oHIV 1 AND 2 ANTIBODY HIV oTSH CASCADE THYROID oHOMOCYSTINE HOMOCY oUA (MICROSCOPIC RRFLXD) UA oIRON, TOTAL IRON oUA (CULTURE RFLX) UA RFX C&S oLIPASE LIP oPSA - DIAGNOSTIC PSA oMAGNESIUM MG oPSA - SCREENING PSA oMICROALBUMIN RANDOM MICALB oAMYLASE AMY oOCCULT BLOOD OCCBLD oCBC W/DIFF CBCDIF oPARATHROID HRMNE PTH oCALCIUM CA oPHENYTON DILANTIN oCEA,S CEA oPHOSPHORUS PHOS oCHOLESTEROL CHOL oPOTASSIUM K oCKMB ISOENZYMES CKMBISO oPT W/INR PT oCPK CPK oPTT - ACTIVATED PTT oCREATINNE CREAT oRETICULOCYTE COUNT RETIC oCRP, INFLAMMATORY CRP oT3-FREE T3FREE oCRP, HIGH SENS CARDIAC CRP-HS oTHYROXINE(T4),FREE T4FREE oESR - SED RATE ESR oTRANSFERRIN TRANS oFERRITIN FERR oTIBC:IRON & TRANSFERRIN TIBC oFOLATE FOLATE oTROPONIN TROPT oGLUCOSE FASTING GLU oURIC ACID URIC oHEPATITIS B SURF. AG HBSAG oVITAMIN B12,S VITB12 oHEMOGLOBIN A1C GLYCO oVIT.D 25-HD D3,S VIT.D-2 ADDITONAL TEST o _______________________________________________________________________ o _______________________________________________________________________ o _______________________________________________________________________ *BILLING INFO - Include a copy of the Medicare card on the intial visit. Write "Currently On File" if copy of card is in lab. For Insurance bill patients, ALWAYS send copy of the card

Req Completed By: (initials)___________ Date:_____________

PRIORITY: oAngel Farnis 100008 oAngelina Postoev 100009 oChris Ibikunle 100007 oChristian Cruz 100006 oChristopher Kacsmarski 100005

oROUTINE

oASAP

oSTAT

LABORATORY REQUISITION