BILL TO: PRINT PATIENT NAME (LAST, FIRST, MIDDLE) Rheumatology MY ACCOUNT PATIENT REGISTRATION # (IF APPLICABLE) DATE M M D D YEAR SEX MEDICARE OF RAILROAD MEDICARE BIRTH MEDICAID PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID # Lab Card/Select OTHER INSURANCE - - ROOM # LAB REFERENCE # PATIENT PHONE # Panel Components Are Listed On The Back. ( ) Reflex Tests Are Performed At PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
ACCOUNT #: KNOW An Additional Charge.
NAME: PSC Appointment Website And Telephone PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY # ADDRESS: Number Information Listed On The Back. CITY, STATE, ZIP STATE ZIP Each Sample Should Be Labeled With At Least CITY TELEPHONE #: Two Patient Identifiers At Time Of Collection. DID YOU DID MEDICARE DATE COLLECTED TIME AM TOTAL VOL/HRS. Fasting NUMBER SUFFIX : PM ML HR Non Fasting MEDICAID 1 NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED) NUMBER STATE RELATIONSHIP TO INSURED: SELF SPOUSE DEPENDENT PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID # GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient) PRIMARY INSURANCE PRIMARY - - Medicare @ = May not be covered for the reported diagnosis. Provide ADDIT’L PHYS.: Dr. NPI/UPIN Limited F = Has prescribed frequency rules for coverage. signed NON-PHYSICIAN NAME I.D.# Coverage & = A test or service performed with research/experimental kit. ABN when PROVIDER: Tests B = Has both diagnosis and frequency-related coverage limitations. necessary អ Fax Results to: ( ) ICD Codes (enter all that apply) Send Client # OR NAME: Duplicate ADDRESS: Report to: CITY: STATE ZIP FOLD FOLD HERE RHEUMATIC AND RELATED SYSTEMIC DISEASES SYSTEMIC LUPUS ERYTHEMATOSUS AND COMPLICATIONS SCLERODERMA, MYOSITIS AND OVERLAP SYNDROMES HERE 249 ឣ ANA, IFA with Reflex to Titer and Pattern S 255 ឣ DNA (ds) Antibody, (Immuno Bead) S 4942 ឣ Scleroderma (Scl-70) Antibody S ឣ 16093 ឣ DNA (ds) Antibody, High Avidity ELISA, (Farrzyme) S 16814 ANA, IFA with Reflex to Titer/Pattern/Cascade S 16088 ឣ Centromere B Antibody S 19946 ឣ ANAchoice®, Specific Antibody Cascade S 37092 ឣ DNA (ds) Antibody, Crithidia IFA with Refl ex to Titer S 5810 ឣ Jo-1 Antibody S 4420 ឣ C-Reactive Protein (CRP) S 34088 ឣ Chromatin (Nucleosomal) Antibody S ឣ 809 ឣ Erythrocyte Sedimentation Rate, Westergren (ESR) WBL 37056 ឣ Histone Antibodies S 37103 PM-Scl Antibody SR 7448 ឣ Sm and Sm/RNP Antibodies S RHEUMATOID ARTHRITIS AND OTHER ARTHROPATHIES VASCULITIS 37923 ឣ Sm Antibody S ឣ ឣ 91472 IdentRA™ Panel with 14-3-3 (eta) Protein S 19887 ឣ RNP Antibody S 36562 Cryoglobulin (% Cryocrit) ឣ 4418 Rheumatoid Factor SST 19899 ឣ RNA Polymerase III Antibody S 37358 ឣ Cryoglobulin Screen w/Reflex to Cryoglobulin Profile ឣ 11173 Cyclic Citrullinated Peptide (CCP) Antibody (IgG) S 7079 ឣ Lupus Anticoagulant Evaluation with Refl ex 257 ឣ Glomerular Basement Membrane Antibody (IgG) S 91455 ឣ 14-3-3 (eta) Protein S ឣ 17408 PTT-LA FPLB 70159 ឣ ANCA Screen with MPO and PR3, w/Reflex to ANCA Titer S 19705 ឣ Rheumatoid Factor (IgA, IgG, IgM) SR 15780 ឣ dRVVT Screen with Reflex to dRVVT Confirm and dRVVT 1:1 Mix FPLB 34151 ឣ Proteinase-3 Antibody S 15682 ឣ Rheumatoid Factor (IgA) SR 883 ឣ Thrombin Clotting Time 15683 ឣ Rheumatoid Factor (IgG) SR 7352 ឣ Cardiolipin Antibodies (IgG, IgA, IgM) PLB 8796 ឣ Myeloperoxidase Antibody (MPO) S ឣ 7832 Sjögren’s Antibodies (SS-A, SS-B) S 4662 ឣ Cardiolipin Antibodies (IgG) PLB AUTOIMMUNE ENCEPHALOPATHIES AND NEUROPATHIES 38568 ឣ Sjögren’s Antibody (SS-A) S 4661 ឣ Cardiolipin Antibodies (IgA) PLB 34283 ឣ Ribosomal P Antibody S 38569 ឣ Sjögren’s Antibody (SS-B) S 4663 ឣ Cardiolipin Antibodies (IgM) PLB ឣ 7085 ឣ Multiple Sclerosis Panel 2 ACUTE ONSET ARTHRITIS 30340 ß2-Glycoprotein I Antibodies (IgA, IgG, IgM) PLB 36552 ឣ ß2-Glycoprotein I Antibodies (IgA) PLB 223 ឣ Albumin S 34296 ឣ Parvovirus B19 DNA, Qualitative, Real-Time PCR ឣ ឣ 36554 ß2-Glycoprotein I Antibodies (IgG) PLB 674 ឣ Oligoclonal Bands (IgG), CSF 8948 Parvovirus B19 Antibody (IgM) S 36553 ឣ ß2-Glycoprotein I Antibodies (IgM) PLB ឣ 663 ឣ Myelin Basic Protein, CSF 8945 Parvovirus B19 Antibody (IgG) S 37097 ឣ Epidermal Antibodies with Refl ex to Titer S ឣ ឣ 37673 Rubella Antibodies (IgG, IgM) S 16033 ឣ Desmoglein (1 and 3) Antibodies 7558 IgG Synthesis Rate/Index, CSF ឣ 802 Rubella Immune Status (IgG) S 16034 ឣ Bullous Pemphigoid BP180 (IgG) S 37093 ឣ Ganglioside GM1 Antibodies (IgG, IgM) S ឣ 4422 Rubella Antibody (IgM) S 16136 ឣ Bullous Pemphigoid BP230 (IgG) S 38836 ឣ Ganglioside Asialo-GM1 Antibody (IgM) S 905 ឣ Uric Acid SST ឣ 10104 Myasthenia Gravis Panel 2 S 39462 ឣ Ganglioside Asialo-GM1 Antibody (IgG) S 265 ឣ Anti-Streptolysin O Antibody (ASO) S 206 ឣ Acetylcholine Receptor Binding Antibody S 38964 ឣ Ganglioside GD1a Antibody (IgM) S 5617 ឣ Streptococcus Group B Culture* 26474 ឣ Acetylcholine Receptor Modulating Antibody S 480 ឣ Neisseria gonorrhoeae (GC), Culture* 34459 ឣ Acetylcholine Receptor Blocking Antibody S 37439 ឣ Ganglioside GD1b Antibody (IgM) S 6646 ឣ Lyme Disease Antibody w/Reflex to Blot (IgG, IgM) S 266 ឣ Striated Muscle Antibody with Refl ex to Titer S * Additional charge for ID and Susceptibilities ADDITIONAL TESTS: (MUST INCLUDE COMPLETE TEST NAME AND ORDER CODE. REFER TO DIRECTORY OF SERVICES.) ∆ Please visit QuestDiagnostics.com/Test Center
COMMENTS, CLINICAL INFORMATION: TOTAL TESTS ORDERED 1 Physician Signature (Required for PA, NY, NJ & WV) For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessary for the diagnosis and treatment of the patient.
SMOOTHSEAL® Quest, Quest Diagnostics, the associated logo and all associated Quest Diagnostics marks are the trademarks of Quest Diagnostics. Copyright © 2003 Quest Diagnostics Incorporated. All rights reserved. www.questdiagnostics.com. All other marks - ®' and ™'- are the property of their respective owner. QD20770A. Revised 1/14. Specimen Key: B = Blue top tube HB = Human breath BX = Unopened Barrier tube L = Lavender top tube FBP = Frozen Plasma Blue top tube PLB = Plasma Light Blue tube FP = Frozen Plasma S = Serum FPL = Frozen Plasma Lavender top tube SR = Serum from a Red top tube FPLB = Frozen Plasma Light Blue tube SST = Spun Barrier tube FS = Frozen Serum TN = Tan top tube (EDTA) GN = Green top tube (Sodium Heparin) WBL = Whole blood Lavender top tube GY = Gray top tube Y = Yellow top tube
7085 10104 16814 - ANA Screen, 19946 - ANAchoice® 91472 - Rheumatoid 7079 - Lupus 37358 - Cryoglobulin Multiple Sclerosis Myasthenia Gravis IFA with Reflex to Titer/ Specific Antibody Arthritis Diagnostic Anticoagulant Screen with Reflex to Panel 2 Panel 2 Pattern/Cascade Cascading Reflex Panel IdentRA™ with Evaluation with Reflex Cryoglobulin Profile 14-3-3 eta 206 - Acetylcholine 249 - ANA IFA Screen 4418 - Rheumatoid Cryocrit Immunodiffusion 223 - Albumin Receptor w/Refl ex to Titer and 255 - dsDNA Antibody 17408 - PTT-LA Factor Binding Antibody Pattern, IFA 26474 - Acetylcholine 11173 - Cyclic 7558 - IgG Synthesis 7448 - Sm and Sm/RNP Receptor 255 - dsDNA Antibody Citrullinated Peptide 15780 - dRVVT Cryocrit Immunofi xation Rate/Index, CSF Antibodies Modulating Antibody (CCP) Antibody (IgG) 34459 - Acetylcholine 663 - Myelin Basic 91455 - 14-3-3 (eta) Receptor 7448 - Sm/RNP Antibody 19887 - RNP Antibody 4418 - Rheumatoid Factor Protein (MBP) CSF Protein Blocking Antibody
674 - Oligoclonal Bands, 37923 - Sm Antibody 37923 - Sm Antibody CSF
34088 - Chromatin 19887 - RNP Antibody Antibody
34088 - Chromatin Antibody
Patients: Minimize your wait time by scheduling an appointment at a convenient Patient Service Center. To find a location and make an appointment visit us at QuestDiagnostics.com/appointment or call 888-277-8772 or simply download our mobile app. at QuestDiagnostics.com/mobile BILL TO: PRINT PATIENT NAME (LAST, FIRST, MIDDLE) Rheumatology MY ACCOUNT PATIENT REGISTRATION # (IF APPLICABLE) DATE M M D D YEAR SEX MEDICARE OF RAILROAD MEDICARE BIRTH MEDICAID PATIENT SOCIAL SECURITY # OFFICE / PATIENT ID # Lab Card/Select OTHER INSURANCE - - ROOM # LAB REFERENCE # PATIENT PHONE # Panel Components Are Listed On The Back. ( ) Reflex Tests Are Performed At PRINT NAME OF INSURED/RESPONSIBLE PARTY (LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
ACCOUNT #: KNOW An Additional Charge.
NAME: PSC Appointment Website And Telephone PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY) APT. # KEY # ADDRESS: Number Information Listed On The Back. CITY, STATE, ZIP STATE ZIP Each Sample Should Be Labeled With At Least CITY TELEPHONE #: Two Patient Identifiers At Time Of Collection. DID YOU DID MEDICARE DATE COLLECTED TIME AM TOTAL VOL/HRS. Fasting NUMBER SUFFIX : PM ML HR Non Fasting MEDICAID 1 NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED) NUMBER STATE RELATIONSHIP TO INSURED: SELF SPOUSE DEPENDENT PRIMARY INSURANCE CO. NAME
MEMBER / INSURED ID # GROUP #
INSURANCE ADDRESS
CITY STATE ZIP
EMPLOYER NAME/EMPLOYER # INSURED SOCIAL SECURITY # (if not patient) PRIMARY INSURANCE PRIMARY - - Medicare @ = May not be covered for the reported diagnosis. Provide ADDIT’L PHYS.: Dr. NPI/UPIN Limited F = Has prescribed frequency rules for coverage. signed NON-PHYSICIAN NAME I.D.# Coverage & = A test or service performed with research/experimental kit. ABN when PROVIDER: Tests B = Has both diagnosis and frequency-related coverage limitations. necessary អ Fax Results to: ( ) ICD Codes (enter all that apply) Send Client # OR NAME: Duplicate ADDRESS: Report to: CITY: STATE ZIP FOLD FOLD HERE RHEUMATIC AND RELATED SYSTEMIC DISEASES SYSTEMIC LUPUS ERYTHEMATOSUS AND COMPLICATIONS SCLERODERMA, MYOSITIS AND OVERLAP SYNDROMES HERE 249 ឣ ANA, IFA with Reflex to Titer and Pattern S 255 ឣ DNA (ds) Antibody, (Immuno Bead) S 4942 ឣ Scleroderma (Scl-70) Antibody S ឣ 16093 ឣ DNA (ds) Antibody, High Avidity ELISA, (Farrzyme) S 16814 ANA, IFA with Reflex to Titer/Pattern/Cascade S 16088 ឣ Centromere B Antibody S 19946 ឣ ANAchoice®, Specific Antibody Cascade S 37092 ឣ DNA (ds) Antibody, Crithidia IFA with Refl ex to Titer S 5810 ឣ Jo-1 Antibody S 4420 ឣ C-Reactive Protein (CRP) S 34088 ឣ Chromatin (Nucleosomal) Antibody S ឣ 809 ឣ Erythrocyte Sedimentation Rate, Westergren (ESR) WBL 37056 ឣ Histone Antibodies S 37103 PM-Scl Antibody SR 7448 ឣ Sm and Sm/RNP Antibodies S RHEUMATOID ARTHRITIS AND OTHER ARTHROPATHIES VASCULITIS 37923 ឣ Sm Antibody S ឣ ឣ 91472 IdentRA™ Panel with 14-3-3 (eta) Protein S 19887 ឣ RNP Antibody S 36562 Cryoglobulin (% Cryocrit) ឣ 4418 Rheumatoid Factor SST 19899 ឣ RNA Polymerase III Antibody S 37358 ឣ Cryoglobulin Screen w/Reflex to Cryoglobulin Profile ឣ 11173 Cyclic Citrullinated Peptide (CCP) Antibody (IgG) S 7079 ឣ Lupus Anticoagulant Evaluation with Refl ex 257 ឣ Glomerular Basement Membrane Antibody (IgG) S 91455 ឣ 14-3-3 (eta) Protein S ឣ 17408 PTT-LA FPLB 70159 ឣ ANCA Screen with MPO and PR3, w/Reflex to ANCA Titer S 19705 ឣ Rheumatoid Factor (IgA, IgG, IgM) SR 15780 ឣ dRVVT Screen with Reflex to dRVVT Confirm and dRVVT 1:1 Mix FPLB 34151 ឣ Proteinase-3 Antibody S 15682 ឣ Rheumatoid Factor (IgA) SR 883 ឣ Thrombin Clotting Time 15683 ឣ Rheumatoid Factor (IgG) SR 7352 ឣ Cardiolipin Antibodies (IgG, IgA, IgM) PLB 8796 ឣ Myeloperoxidase Antibody (MPO) S ឣ 7832 Sjögren’s Antibodies (SS-A, SS-B) S 4662 ឣ Cardiolipin Antibodies (IgG) PLB AUTOIMMUNE ENCEPHALOPATHIES AND NEUROPATHIES 38568 ឣ Sjögren’s Antibody (SS-A) S 4661 ឣ Cardiolipin Antibodies (IgA) PLB 34283 ឣ Ribosomal P Antibody S 38569 ឣ Sjögren’s Antibody (SS-B) S 4663 ឣ Cardiolipin Antibodies (IgM) PLB ឣ 7085 ឣ Multiple Sclerosis Panel 2 ACUTE ONSET ARTHRITIS 30340 ß2-Glycoprotein I Antibodies (IgA, IgG, IgM) PLB 36552 ឣ ß2-Glycoprotein I Antibodies (IgA) PLB 223 ឣ Albumin S 34296 ឣ Parvovirus B19 DNA, Qualitative, Real-Time PCR ឣ ឣ 36554 ß2-Glycoprotein I Antibodies (IgG) PLB 674 ឣ Oligoclonal Bands (IgG), CSF 8948 Parvovirus B19 Antibody (IgM) S 36553 ឣ ß2-Glycoprotein I Antibodies (IgM) PLB ឣ 663 ឣ Myelin Basic Protein, CSF 8945 Parvovirus B19 Antibody (IgG) S 37097 ឣ Epidermal Antibodies with Refl ex to Titer S ឣ ឣ 37673 Rubella Antibodies (IgG, IgM) S 16033 ឣ Desmoglein (1 and 3) Antibodies 7558 IgG Synthesis Rate/Index, CSF ឣ 802 Rubella Immune Status (IgG) S 16034 ឣ Bullous Pemphigoid BP180 (IgG) S 37093 ឣ Ganglioside GM1 Antibodies (IgG, IgM) S ឣ 4422 Rubella Antibody (IgM) S 16136 ឣ Bullous Pemphigoid BP230 (IgG) S 38836 ឣ Ganglioside Asialo-GM1 Antibody (IgM) S 905 ឣ Uric Acid SST ឣ 10104 Myasthenia Gravis Panel 2 S 39462 ឣ Ganglioside Asialo-GM1 Antibody (IgG) S 265 ឣ Anti-Streptolysin O Antibody (ASO) S 206 ឣ Acetylcholine Receptor Binding Antibody S 38964 ឣ Ganglioside GD1a Antibody (IgM) S 5617 ឣ Streptococcus Group B Culture* 26474 ឣ Acetylcholine Receptor Modulating Antibody S 480 ឣ Neisseria gonorrhoeae (GC), Culture* 34459 ឣ Acetylcholine Receptor Blocking Antibody S 37439 ឣ Ganglioside GD1b Antibody (IgM) S 6646 ឣ Lyme Disease Antibody w/Reflex to Blot (IgG, IgM) S 266 ឣ Striated Muscle Antibody with Refl ex to Titer S * Additional charge for ID and Susceptibilities ADDITIONAL TESTS: (MUST INCLUDE COMPLETE TEST NAME AND ORDER CODE. REFER TO DIRECTORY OF SERVICES.) ∆ Please visit QuestDiagnostics.com/Test Center
COMMENTS, CLINICAL INFORMATION: TOTAL TESTS ORDERED 1 Physician Signature (Required for PA, NY, NJ & WV) For any patient of any payor (including Medicare and Medicaid), only order those tests which are medically necessary for the diagnosis and treatment of the patient.
SMOOTHSEAL® Quest, Quest Diagnostics, the associated logo and all associated Quest Diagnostics marks are the trademarks of Quest Diagnostics. Copyright © 2003 Quest Diagnostics Incorporated. All rights reserved. www.questdiagnostics.com. All other marks - ®' and ™'- are the property of their respective owner. QD20770A. Revised 1/14. Specimen Key: B = Blue top tube HB = Human breath BX = Unopened Barrier tube L = Lavender top tube FBP = Frozen Plasma Blue top tube PLB = Plasma Light Blue tube FP = Frozen Plasma S = Serum FPL = Frozen Plasma Lavender top tube SR = Serum from a Red top tube FPLB = Frozen Plasma Light Blue tube SST = Spun Barrier tube FS = Frozen Serum TN = Tan top tube (EDTA) GN = Green top tube (Sodium Heparin) WBL = Whole blood Lavender top tube GY = Gray top tube Y = Yellow top tube
7085 10104 16814 - ANA Screen, 19946 - ANAchoice® 91472 - Rheumatoid 7079 - Lupus 37358 - Cryoglobulin Multiple Sclerosis Myasthenia Gravis IFA with Reflex to Titer/ Specific Antibody Arthritis Diagnostic Anticoagulant Screen with Reflex to Panel 2 Panel 2 Pattern/Cascade Cascading Reflex Panel IdentRA™ with Evaluation with Reflex Cryoglobulin Profile 14-3-3 eta 206 - Acetylcholine 249 - ANA IFA Screen 4418 - Rheumatoid Cryocrit Immunodiffusion 223 - Albumin Receptor w/Refl ex to Titer and 255 - dsDNA Antibody 17408 - PTT-LA Factor Binding Antibody Pattern, IFA 26474 - Acetylcholine 11173 - Cyclic 7558 - IgG Synthesis 7448 - Sm and Sm/RNP Receptor 255 - dsDNA Antibody Citrullinated Peptide 15780 - dRVVT Cryocrit Immunofi xation Rate/Index, CSF Antibodies Modulating Antibody (CCP) Antibody (IgG) 34459 - Acetylcholine 663 - Myelin Basic 91455 - 14-3-3 (eta) Receptor 7448 - Sm/RNP Antibody 19887 - RNP Antibody 4418 - Rheumatoid Factor Protein (MBP) CSF Protein Blocking Antibody
674 - Oligoclonal Bands, 37923 - Sm Antibody 37923 - Sm Antibody CSF
34088 - Chromatin 19887 - RNP Antibody Antibody
34088 - Chromatin Antibody
Patients: Minimize your wait time by scheduling an appointment at a convenient Patient Service Center. To find a location and make an appointment visit us at QuestDiagnostics.com/appointment or call 888-277-8772 or simply download our mobile app. at QuestDiagnostics.com/mobile