11736 Lab Req Red-Blue

3550 W. Peterson Ave., Ste. 100 ACCOUNT: Chicago, Illinois 60659 Tel: 773-478-6333 Fax: 773-478-6335 LABORATORY REQUISITION PATIENT NAME - LAST FIRST MIDDLE INITIAL

PATIENT IDENTIFICATION SOCIAL SECURITY NO. DATE OF BIRTH SEX N O I NAME OF INSURED SS# OF INSURED RELATIONSHIP TO PATIENT T A M R

O PATIENT/INSURED ADDRESS PHONE NUMBER MEDICARE NO. (INCLUDING ALPHA CHARACTERS) F Please attach an ABN form. N I

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N CITY STATE ZIP CODE I L L I MEDICAID NO. B BILL I PHYSICIAN I PATIENT I MEDICARE I MEDICAID I INSURANCE (attach copy of both sides of card) TO ACCOUNT DIAGNOSIS (CD-9 CODE(S)) (REQUIRED FOR 3RD PARTY BILLING) PLEASE WRITE PATIENT’S NAME ON ALL SPECIMENS DATE COLLECTED COLLECTED BY AM DR. NAME / NPI # DR. OR RN SIGNATURE PM 001 GENERAL HEALTH PROFILE ( Male ) - CBC, CMP, LIPID, TSH, FT4, TT3, FERRITIN, PSA, H-PYLORI, MAG, ESR, UA, IRON/TIBC SST, L, U 002 GENERAL HEALTH PROFILE ( Female ) - CBC, CMP, LIPID, TSH, FT4, TT3, FERRITIN, H-PYLORI, MAG, ESR, UA, IRON/TIBC SST, L, U 003 AMENOR/MENSTR. DISORDER - CMP, LIPID, CBC, TSH, FT4, TT3, ESR, IRON/TIBC, FERRITIN, MAG, UA, HCG, FSH, LH, PROLACTIN, RET COUNT SST, L, U 004 ANEMIA - CMP, LIPID, IRON/TIBC, CBC, FERRITIN, TSH, FT4, TT3, H-PYLORI, UA, G6PD, RET COUNT SST, L, U 005 ARTHRITIS - CMP, LIPID, CBC, URIC ACID, ESR, ASO, CRP, ANA, RH, SLE SST, L, U 006 DIABETES - CMP, LIPID, CBC, HBA1C, CORTISOL, TSH, FT4, TT3, UA, RET COUNT SST, L, U 007 HEPATITIS - HAAB IGM, HBCAB IGM, HBSAB, HBSAG, HCAB, SGOT, SGPT SST 008 HYPERTENSION/CARDIAC - CMP, LIPID, CBC, TSH, FT4, TT3, IRON/TIBC, CPK, CORTISOL, MAG, UA, RET COUNT, FERRITIN SST, L, U 009 KIDNEY - CMP, LIPID PANEL, CBC, RETIC CT., U/A, ASO, CRP, U/CS, ESR, MAG, CORTISOL SST, L, U 010 LIVER - CMP, LIPID, CBC, ESR, PT/INR, IRON/TIBC, TSH, FT4, TT3, FERRITIN, UA, CRP, HBSAG, HBSAB,RET COUNT, PTT, AMYLASE, LIPASE SST, L, U, B 011 OBSTETRIC - CMP, LIPID, CBC, TSH, FT4, TT3, FERRITIN, UA, HBSAG, RET COUNT, RPR, ABORH, RUBELLA SST, L, U 012 PRENATAL - CMP, LIPID, CBC, FERRITIN, TSH, FT4, TT3, IRON/TIBC, HIV, B-HCG QNT, UA, RPR, RET COUNT, ABORH, RUBELLA, HBSAG SST, L, U 013 THYROID/OBESITY - CMP, LIPID, CBC, TSH, FT4, TT3, CORTISOL, UA, RET COUNT SST, L, U TUBE KEY: B-Blue G-Grey L-Lavendar SST-Tiger R-Red Y-Yellow U-Urine (tube) Us-Urine (sterile cup) Sw-Culture Swab PROFILES: THESE PROFILES MADE FOR PHYSICIAN CONVENIENCE, BUT PHYSICIAN COULD ORDER INDIVIDUAL TESTS OR REQUEST CUSTOM PROFILES. INDIVIDUAL TESTS () 100 AMYLASE SST 121 HEPATITIS B, CORE AB SST 141 RF - RHEUMATOID FACTOR SST MICROBIOLOGY 101 ANA (EIA) SST 122 HEPATITIS B, SURFACE AB SST 142 RPR SST 162 BLOOD CULTURE Blood C.Vials 102 ANTIBODY SCREEN SST 123 HEPATITIS B, SURFACE AG SST 143 RUBELLA IgG SST 163 CULTURE MRSA w/ REFLEX CONFIRM 103 ASO SST 144 SED RATE (ESR) L 164 GC CULTURE 124 H. pylori SST 104 BASIC MET. PANEL SST 145 SICKLE CELL L 165 OCCULT BLOOD S.CUP 125 HIV ANTIBODY SST 146 TEGRETOL RED 105 BNP L 166 OCCULT BLOOD X1 126 HOMOCYSTEINE SST/L 147 TESTOSTERONE SST 106 CBC DIFF L 167 OCCULT BLOOD X3 107 CEA RED 127 LDL- Direct SST 148 TESTOSTERONE PANEL RED & SST (Total/Free & Estrogen) 168 OVA & PARASITES TR. Media 108 CHEMSCAN-INCLUDES SST 128 LH SST 169 SPUTUM CULTURE S.CUP CMP, LIPID PANEL, F e, GGTP, CPK 129 LIPASE SST 149 THEOPHYLLINE RED 109 COMPLETE METABOLIC PANEL SST 130 LIPID PANEL-INCLUDES SST 150 T3-UPTAKE SST 170 STOOL CULTURE 110 CRP CARDIAC SENSITIVE SST CHOL, HDL, LDL, TRIG 151 T4 TOTAL SST 171 Streptococcus, Group A Sw With Reflex to Culture 111 DIGOXIN RED 131 MAGNESIUM SST 152 T4 FREE SST 172 THROAT CULTURE Sw 112 DILANTIN RED 132 MICROALBUMIN U 153 THYROID PROFILE (TSH, FT4, TT3) SST 173 URETHRAL CULTURE Sw 113 ELECTROLYTES SST 133 PHENOBARBITAL RED 154 TIBC 174 URINE CULTURE & S S.CUP 114 ESTRADIOL SST 134 PREGNANCY URINE U 155 TROPONIN GREEN/SST 115 FERRITIN SST 135 PREGNANCY SERUM SST 156 TSH SST 175 VAGINAL CULTURE Sw 116 FOLIC ACID SST 136 PROLACTIN SST 157 URIC ACID SST 176 WOUND CULTURE Sw 117 FSH SST 137 PSA SST 158 URINALYSIS S.CUP CYTOLOGY 118 GLUCOSE FBS G 138 PT w/INR B 159 VAGINAL G p B SCREEN Sw 177 GYN PAP Smear, Conventional 119 GLYCO Hgb A1c L 139 PTT B 160 VITAMIN B12 / FOLATE SST 178 GYN PAP, ThinPrep 120 HEPATITIS A, AB SST 140 RETIC COUNT L 161 VITAMIN D25 HYDROXY SST 179 GYN PAP with HPV Reflex (ThinPrep Only) OTHER TESTS:

DIAGNOSIS CODES: FOR LAB USE ONLY: I Abdominal Pain 78900 I Diabetes 25000 I Hepatitis 5733 I Obesity 27800 I Rhinitis Allergy 4779 I I Abnormal Blood Chem 7906 I Diarrhea 5589 Hyperlipidemia 2724 I Other Nonspecific Finding 79099 I Rhinoplasty 7385 I Hypertension 4019 I I I Abnormal Glucose 79029 I Dysuria 7881 Otitis 3829 Routine Child health check V202 I Hyperthyroidism 24290 I Peripheral 4439 I Seizure Disorder 78039 I Amenorrhea 6260 I Epilepsy 34590 I Hypothyroidism 2449 I Vascular Disease I Sinusitis 4619 I Anemia 2859 I Fatigue 78079 I Kidney Disease 5939 I Pharangytis 462 I Strep Throat 463 I Angina 4139 I Fever 7806 I Laboratory Exam V726 I PID 6149 I Thrombophlebitis 4519 I Arthritis 71690 I Follow-up Exam V6759 I Liver Disease 5739 I Pneumonia 4829 I Thyroid Dysfn. 2469 I I Gastritis 53550 Asthma 49390 I Long-term use of I Pregnancy V222 I Tubal Ligation V259 I Bursitis 7273 I Gonorrhea 0980 anticoagulants V5861 I I I Pregnancy-Negative V7241 Ulcer Peptic 53390 I Chest Pain 78650 I Gout 2749 Long-term use of other medications V5869 I Pre-operative Exam V7284 I Urethritis NOS 59780 I I Hammer Toe 7354 CHF 4280 I Menopause Syn. 6272 I Prostate-Hypertroph (BPH) 60000 I UTI 5990 I I Cystitis 5950 Headache 7840 I Menstrual Irreg. 6264 I Prostate Screening V7644 I Vaginitis 61610 I Depression 311 I Hematuria 5997 I Metabolic Syndrome 2777 I Prostitis 6019 I Varicose Veins 454.1 I Dermatitis 6929 I Hemorrhoids 4552 I Neoplasm 1991 I Rheum. Arthritis 7140 I Vasectomy V252 COMMON ICD-9 DIAGNOSIS CODES To avoid unwarranted denials and subsequent rework for office staff, any requisitions sent to MedLab Inc. must include all medically appropriate ICD-9 diagnosis codes. ICD-9 codes are required by certain third party payors to confirm the medical necessity of the test(s) and/or profile(s) ordered. Below are ICD-9 codes most commonly received by MedLab Inc. These codes were taken from the ICD-9 manual issued by the American Medical Association. While this list may be a useful reference tool depending upon the nature of your practice, it is not complete. Please refer to the ICD-9 manual for a complete listing. The ultimate responsibility for correct coding lies with the ordering physician. Please place all medically appropriate ICD-9 code(s) on the front of the requisition in the designated diagnosis code field. If ordering testing solely for screening purposes, please provide the appropriate screening ICD-9 code(s).

CODE DIAGNOSIS (symptom, illness, injury, or complaint) 794.8 Liver scan, abnormal 789.00 Abdominal pain, unspecified site 724.2 Lumbago 790.6 Abnormal blood chemistry, other 780.7 Malaise & fatigue 796.4 Abnormal clinical findings, other 162.9 Malignant neoplasm of bronchus & lung, unspecified 706.1 Acne, other 153.9 Malignant neoplasm of colon, unspecified 496 Airway obstruction, chronic, not elsewhere classified 174.9 Malignant neoplasm of female breast, unspecified 477.9 Allergic rhinitis, cause unspecified 183.0 Malignant neoplasm of ovary 280.9 Anemia, iron deficiency, unspecified 185 Malignant neoplasm of prostate 281.0 Anemia, pernicious 627.2 Menopausal or female climacteric states 285.9 Anemia, unspecified 626.4 Menstrual cycle, irregular 413.9 Angina pectoris, other & unspecified 626.8 Menstruation, suppression of; dysfunc, uterine hemorrhage NOS 424.1 Aortic valve disorders 626.0 Menstruation, absence of 716.90 Arthropathy, unspecified, site unspecified 626.2 Menstruation, excessive or frequent 493.90 Asthma, unspecified, without mention of status asthmaticus 625.3 Menstruation, painful 427.31 Atrial fibrillation 424.0 Mitral valve disorders 724.5 Backache, unspecified 799.9 Morbidity & mortality, other unknown and unspecified cause 466.0 Bronchitis, acute 729.1 Myalgia & myositis, unspecified 427.9 Cardiac dysrhythmia, unspecified 238.2 Neoplasm of uncertain behavior of skin 425.4 Cardiomyopathies, primary, other 278.01 Obesity, morbid 429.2 Cardiovascular disease, unspecified 278.00 Obesity, unspecified 436 Cerebrovascular disease, acute but ill-defined (CVA NOS, stroke) 715.09 Osteoarthrosis, generalized, multiple sites 616.0 Cervicitis & endocervicitis 715.90 Osteoarthrosis, unspecified whether generalized or localized, site unspecified 786.50 Chest pain, unspecified 733.00 Osteoporosis, unspecified 286.9 Coagulation defects, other & unspecified 785.1 Palpitations 428.0 Congestive heart failure 795.0 Papanicolaou smear of cervix abnormality, nonspecific 780.31 Convulsions, febrile 443.9 Peripheral vascular disease, unspecified 780.39 Convulsions, other 462 Pharyngitis, acute 414.01 Coronary atherosclerosis of native coronary artery 486 Pneumonia, organism unspecified 414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft 627.3 Postmenopausal atrophic vaginitis 786.2 Cough 790.93 Prostate specific antigen (PSA) elevation 311 Depressive disorder, not elsewhere classified 600 Prostatic hyperplasia 110.1 Dermatophytosis of nail 601.9 Prostatitis, unspecified 250.01 Diabetes mellitus, type I (IDDM), not stated as uncontrolled 585 Renal failure, chronic 250.00 Diabetes mellitus, type II (NIDDM) or unspecified type, not stated as uncontrolled 714.0 Rheumatoid arthritis 250.02 Diabetes mellitus, type II (NIDDM) or unspecified type, uncontrolled 461.9 Sinusitis, acute, unspecified 787.91 Diarrhea 473.9 Sinusitis, chronic, unspecified 780.4 Dizziness & giddiness 034.0 Streptococcal sore throat 995.2 Drug, medicinal & biological substance adverse effect, unspecified 780.2 Syncope & collapse 622.1 Dysplasia of cervix (uteri) 710.0 Systemic lupus erythematosus 786.09 Dyspnea & respiratory abnormalities, other 246.9 Thyroid disorder, unspecified 788.1 Dysuria 463 Tonsillitis, acute 782.3 Edema 435.9 Transient cerebral ischemia, unspecified 259.9 Endocrine disorder, unspecified 465.9 Upper respiratory infection, acute, unspecified site 530.81 Esophageal reflux 788.41 Urinary frequency 625.9 Female genital organ symptom, unspecified 599.0 UTI (urinary tract infection), site not specified 780.6 Fever 616.10 Vaginitis & vulvovaginitis, unspecified 558.9 Gastroenteritis & colitis, noninfectious, other & unspecified 783.1 Weight gain, abnormal 780.9 General symptoms, other 783.2 Weight loss, abnormal 274.9 Gout, unspecified V28.8 Antenatal screening, other specified 784.0 Headache V67.51 F/U exam for completed treatment w/high-risk meds, not elsewhere classified 599.7 Hematuria V70.0 General medical examination (routine) at a health care facility 569.3 Hemorrhage of rectum & anus V70.9 General medical examination, unspecified 286.5 Hemorrhagic disorder due to circulating anticoagulants V72.3 Gynecological examination 573.3 Hepatitis, unspecified V20.2 Infant or child health check, routine 042 Human immunodeficiency virus (HIV) disease V20.1 Infant or child (healthy) receiving care, other 272.0 Hypercholesterolemia, pure V42.0 Kidney transplant 272.1 Hyperglyceridemia, pure V72.6 Laboratory examination 272.2 Hyperlipidemia, mixed V58.61 Long term (current) use of anticoagulants 272.4 Hyperlipidemia, other & unspecified V58.69 Long term (current) use of other medications 401.1 Hypertension, essential, benign V70.3 Medical examination for administrative purposes, other 401.0 Hypertension, essential, malignant V22.0 Normal first pregnancy supervision 401.9 Hypertension, essential, unspecified V22.1 Normal pregnancy (other) supervision 402.10 Hypertensive heart disease, benign, without congestive heart failure V71.9 Observation for unspecified suspected condition 402.90 Hypertensive heart disease, unspecified, without congestive heart failure V24.2 Postpartum follow-up, routine 276.8 Hypopotassemia V72.84 Pre-operative examination, unspecified 244.9 Hypothyroidism, unspecified V22.2 Pregnant state, incidental 607.84 Impotence of organic origin V74.5 Special screening examination for bacterial/spirochetal venereal disease 564.1 Irritable colon V72.9 Special investigation & examination, unspecified 414.9 Ischemic heart disease, chronic, unspecified V82.5 Special screening for chemical poisoning and other contamination 719.40 Joint pain, site unspecified V76.2 Special screening for malignant neoplasms, cervix 593.9 Kidney & ureter disorder, unspecified V78.1 Special screening for other and unspecified deficiency anemia 623.5 Leukorrhea, not specified as infective 272.9 Lipoid metabolism disorder, unspecified