I III II iii 3233025- )!RUCE MOSKOWITZ, ND NATIONWIDE ACCOUNT 1411 N RADLER DR STE 7100 WEST PALO DEACH, EL 33401-itill nm" (56624S ME COLLECTED I I BELLI*: C My Account o Insurenos Provided i Lab Catd/Ssui ( Priem nod. PAS salt PAPAL Waal. Pavel. ;._? sit\ n GtSTRA N • IF APPlICABLE) Patient Service Center location and appointmen scheduling information is on the back. Each sample should be labeled with at least two patient identifiers at time of collection. ICD Diagnosis Codes are Mandatory. Fill in the applicable fields below. nia Ij AM TOTAL Yam% OPM pAL I Faettog _ HR D Non Fasting PIARIN ORDERING/SUPERVISING PHYSICIAN ANO/OR PAYORS ) 1376970335 ACCETTUR0.000800 Ser 1306702076 HOSKOMIT2,0RUCE ( i 1477952133 HOWICHENS,PRITTAN (MUST BE INDICATED) ( CCB CICHE ( DOS Z+DLUECRD i HUSK AETNA I ADCITL PLAYS.: Dr. DINS to Mgt viols ADDRESS. twits CITY PANEL CON STATE NENTS ON BACK ORGAN / DISEASE PANELS 34352 7_, Electra Ins Panel MICOMEllaesuc isaction Panel 10155L20mskbr.uprorrusi tenIEComp Metabolic had S 87.00DUpid Panel IFaStlagt 14152 Dip I d Pa n al wfibillex DADL S DE212100 Obstetric hell valleigi V.1.5 'DIEGOEDICipstitis arab* vallellar 5 1/314 Renal Fungal Panel S EISIORHomaglogn I. •3309 Hematocm L etraOcec (HO. MCI. MC, MSC. PIT) L on.HCBC vot•fl figi. Hit litttWOC,FitOR) I. 88847 PI vain IPIR B PTT. Activated B 7788 DABO Grouts & Rs Type y (4237 K AEPTumor Market S zzy Miming S 234 Alkaline ProsphAase $ it23 0 aer $ 243 0 Amyrne $ 249 O anarneniarn weroatter Nam $ 7.6 c Antibody Sc., ROC A/RAW t V 072 CAST $ 225 C011ilybol. WOO 3 117 DBiSrutin.Tosal s COI TIONAl IDIS (INCLUDE C0/.0ETED.ST /Oat Mi0 ORDER CODE) Mlles tests are patterned S S *2903 *39356 *303 11173 897$ 8334 374 375 402 00243 4021 @el 466 470 8482 8477 19833 8444 Bpi 0435 SIM BIN 616892 439 491 6472 _ 891431 31789 ®1507 C ZIP 61571 593 599 C-Reactive Pro