Lab Form_General Requisition Form General
User Manual: LabForm_General-Requisition
Open the PDF directly: View PDF 
.
Page Count: 2
| Download | |
| Open PDF In Browser | View PDF |
THE NATIONAL WOMEN’S HORMONE LABORATORY STANDING ORDER DRAW AND SEND SPECIMEN TO: DATE OF ISSUE:____________ 6901 Mercy Rd. Omaha Ne 68106 Phone: 402-390-0532 Fax: 402-505-8931 DATE OF EXPIRATION:___________ CLIA # 28D043756 Thomas W. Hilgers M.D. Medical Director Thomas W. Hilgers M.D. Laboratory Director PATIENT INFORMATION Name (Last, First)________________________________________________ Date of Birth____/____/_______ Address________________________________________________________ Phone_____-_____-_______ PPVI Account #____________________ Gender MALE / FEMALE *****NEW PATIENTS MUST SEND DEMOGRAPHIC INFORMATION FOR PROCESSING***** BILLING INFORMATION Bill To: Patient Self-Pay / Insurance* / Client *SEND COPY OF INSURANCE CARD (front and back) Insurance__________________________________________ Ordering Provider________________________________________ Subscriber ID_________________ Group #_______________ Provider Phone #_____-_____-_______ Fax # _____-____-______ Name of Policy Holder _______________________________ Signature of Provider (Required)____________________________ ORDER INFORMATION Patient on HCG: Y/N Last Menstrual Period___-___-_____ Cycle Day ____or Peak + _______ OB ETA ___-____-_____ by : US LMP PEAK DAY Gestational Weeks _______Days____ DATE DRAWN____________TIME DRAWN______________INITIALS_________Facility _________________ Phone ____-____-______ □ 84144 PROGESTERONE □ 82670 ESTRADIOL □ 82157 □ 82627 □ 84270 □ 84403 ANDROSTENEDIONE DHEA-SO4 SHBG TOTAL TESTOSTERONE □ 84443 □ 84439 □ 84480 □ 84436 TSH FT4 T3 T4 □ 83001 FSH □ 83002 LH □ 84146 PROLACTIN □ 84702 HCG Quantitative DRAWING INSTRUCTIONS Draw blood into a red top tube or SST/Tiger Top Let specimen clot and spin for 15 minutes (or follow your labs procedure for collecting serum) Submit a minimum of 2 mL serum in an aliquot tube. Label with the patients NAME/DOB/DATE. **DO NOT SEND IN SST** Progesterone, Estradiol and HCG may be room temperature for < 5days, ALL other tests must be sent on ICE PACKS for next day delivery Prepaid shipping kits are available for purchase, please call 402-390-0532 to order a kit DIAGNOSIS Diagnosis is MANDATORY for all Patient and Insurance Billing. Please circle the appropriate Diagnosis. N93.9 Abnormal Uterine Bleeding N91.2 Amenorrhea E28.8 Hyperhormonal N91.0 Primary N91.1 Secondary N91.0 Anovulation E23.6 Anterior Pituitary Disorders N94.6 Dysmenorrhea N94.4 Primary F45.8 Psychogenic N94.5 Secondary N96 Habitual SAB (Hx of) N92.5 E34.9 E28.9 E28.8 N91.1 N92.4 O72.1 N92.4 F45.8 E28.2 Z34.90 O09.891 Irregular Menstruation, Other Low Progesterone Luteal Phase Defect Late Luteal Defect Metrorrhagia Menopausal Postpartum Premenopausal Psychogenic Polycystic Ovaries Pregnancy, Normal # Wks_____ Pregnancy High Risk # Wks____ Z32.00 N94.3 E03.9 E05.90 Z13.29 R53.83 N80.9 N71.1 E28.39 Pregnancy Test, Result unknown Premenstrual Tension Syndrome Hypothyroidism, NOS Hyperthyroidism, Unspecified Thyroid Disorder Screening Fatigue, Other Endometriosis, Unspecified Endometritis, Chronic Other Primary Ovarian Failure Other Diagnosis________________
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.5 Linearized : No Page Count : 2 Language : en-US Tagged PDF : Yes Author : Sarah Bowes Creator : Microsoft® Word 2013 Create Date : 2017:02:07 13:42:17-06:00 Modify Date : 2017:02:07 13:42:17-06:00 Producer : Microsoft® Word 2013EXIF Metadata provided by EXIF.tools