atrol tic 11111 1111111111111 111 17434-0 3934515-7 UCA/110SMOUIT2 BRUCE MD IXDUKT all CR/UNIU.CLINICAL WM: 1411 N FLACLER DR STE 7100 MIEURT PALM BEACH, FL 33401 rileicm?,6115265 561-833-6116 hATEONIECIED TWO r7 Am TOOLVOLAIRS. IWesting G PM HS O Non Fasting JPEUPIN ORLIEFUNG/SUPERVISANO PHYSICIAN ANCYOR PAYORS MST BE INDICATED) ( ) 1386702876 MOSXONITZ,BRUCE U ( ) 1376970395 HARTIN,ANANDA 111 0 My Aocou t nuns= ProAdotl El Lab CardGelect :::111 n Patient Service Center location and appointment scheduling information is on the back. rp fref in • REGISTRA OTAPPUCABLE) Each sample should be labeled with nt lean two patient identifiers at time of collection. PHYS MEDIPASS AUTO # (9) ( ) CCn CIGNA ( ) ENFIR EMPIRE UN ( ) DCBS PEOMECRO ( ) GAMS OXFORD NE ( ) AM AETNA ( ) UNTO UNITED HE ( ) COLOR ;OLDEN RU ADINTL PHYS.: Dr. OiNaNYMCIAN NAVE LOS PROVIDER tax Results to d Gamma arts ADORESS: 'owlet CITY PATIENT SOCIAL SECUNTY I/ N DATE OF BIRTH I I ROOM • LAB RIPERENCI• YEAR I I OFFICE/MENTOS PATIENT PHONE • ) SD PAINT NAME OF INSLPED/IFSV0NSBLE PAM PAST. RASE OS:VW- FOROBIANFATENT I ' , t I ; I I I I I SERENTS/REETADORESSIORINSUREDRESPONSIBLEPARTO APT' KEY/ CITY I I 1 , 1 ; 1 1 i i l l I I nEtATIONSHIPTO INSURED: 0 NAP 0 DITIVOINT STATE ZIP PRIMARY INSURANCE CO. NAME I 1 1 1 1 1 eismriaft /INSURED ID NO.0 • I I I I MSURANCE A STATE_ ZIP Medicare Limited Coverage Tests L i ; STATE I I ZIP 411= May not to covered to the reported diagnosis. F • Has pros:Axe frequency ides for covorego. de .-. A leSt or service corlomme with research /experiment kit B - Has togs diagnosis aro hear onCY-lolal CO"Ine FnItath'IS when e A ir Wean ( )0302946 CP 302966 ( ) 303644 CP 303644 ( ) 307978 CP 307978 0338742 ( ) 223 ( ) 234 ( ) 823 ( ) 5509 ( ) 243 AHYLASE ( ) ( ) 249 ANA IF* U/RFL IFA ( )0 ( ) 822 AST ( )8 ( ) 10165 BASIC MET PHL ( ) ( ) 852 BETA