Health0 iagr tiCLabOratOryl nc. 0002442 - 0168002 or. Morph P.13130anaciiiiitatily Mega GJA No. 490/100708 I CAP No. 7224971 I NH No. 1629209853 INSTRUCTIONS 1) please Min allol the yelew Ng Weed amain% tiding the clognosn code vecton at (Mum tenon of chit requeaston 21 Have the patient sin the Relent and Assignment ol Stoat; semen below 3) lea, Inc. will accept an Malone Demographic Sheet n sublets...le for Panne information provided it melees all required SIIIIIIPSPOI4 II I40-9 codes we Mt Part of your demographic sheet. please pr Me +copy of the Patient Problem List including al ICOJACM cabs For diagnoses. conditions. or symptoms. PhOtChins 10, <Rhea indohcluats aut hooted to order tests, should on), order tests that we intensely necessary and reasonable LAST FIRS1 0002442-0166002 LAST FIRST 0002442-0168002 MATION it last Name: Win Middle Initial: pmj„„11,1,J t 1 1 1 1 1 1 1 4,1. j 1 1 1 1 1 City: IRAN: Cell/Home Insane: Work Phone: Email Address: Pip Code: Social In :Ltspir. hots i Weft ht: LAST LAST FIRST FIRST 0002412-0168002 00024C-0160002 UST FIRST 0002442-016600: LAST FIRST 0002442-0110002 SP. Arts Dr. Paw Ate 4487 Philbrook Squire San Diego, CA 92130 Dori!, Ph PECIMEN INFORMA Rowing Lab. Collection Date: * Phlebotomist's Initials an: dme of last dose: Phone am/pm Fasting:3g Set H's NO " IA s INSURANCE: Please attach a copy oF ROTH Skies et Patient's insurance card. Medicare Number: 0 SELF PAY: HDL Inc. will bill the patient. im Fr ASSIGNMENT OF BENEFITS Ai a mu:ten. Di I every reasonable effort to obtain reimbursement for ordered tests. I au • Tor, re HOI. Inf to re:eait to %led co ie. its carriers, and any insurance carrier or health plan providing medical benelits to me. any 'one motion that may be needed for claim purposes. I consent to submit my sample to SIDS . tor testing. I am making an assignment of Medicare. Medicaid. and/or insurance benefits to HDL Inc. ea to myInstance: