Patient Last, First Name, M

1400 Jackson Street Denver, Colorado 80206 Client Services 800.550.6227, option 6 CHEMISTRY/HEMATOLOGY REQUISITION NJlabs.org [email protected]

FACILITY / CLIENT INFORMATION [PLEASE PRINT] Facility Name Telephone Ordering Physician

Street Fax #1 City State Zip Fax #2 UPIN NPI # PATIENT INFORMATION Patient Diagnosis: ICD-9 Code: [PLEASE PRINT] Patient: First Name Last Name Responsible Party (if other than patient) Male Date of Birth MM/dd/yyyy Relationship to Patient Female Street Address Street Address State City Zip City State Zip

Telephone Telephone Bill Up front payment (check / credit Client Patient Medicare CO Medicaid to: card) **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 PHONE NUMBER City SUBSCRIBER SUBSCRIBER DOB State ZIP 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 REFERRAL LAB 300 (09.30.10) 1400 Jackson Street Denver, Colorado 80206 Client Services 800.550.6227, option 6 CHEMISTRY/HEMATOLOGY REQUISITION NJlabs.org [email protected]

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 Thyroid Panel THYPX (Total T4, T3 Uptake, FTI)

REFERRAL LAB 300 (09.30.10)