Lab Form_PMS Series Requisition Form PMS
User Manual: LabForm_PMS--Series-Requisition
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THE NATIONAL WOMEN’S HORMONE LABORATORY DRAW AND SEND SPECIMEN TO: 6901 Mercy Rd. Omaha Ne 68106 Phone: 402-390-0532 Fax: 402-505-8931 Thomas W. Hilgers M.D. Medical Director Thomas W. Hilgers M.D. Laboratory Director CLIA # 28D043756 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 PMS HORMONE PROFILE COMPLETE LUTEAL FUNCTION PROFILE (Post-Peak Series) – Complete PEAK +3 PROGESTERONE* ESTRADIOL DATE/TIME DRAWN___________ INITIALS____ PEAK +5 PROGESTERONE* ESTRADIOL DATE/TIME DRAWN___________ INITIALS____ DRAWING INSTRUCTIONS PMS Profile COMPLETE: On P+3 begin Drawing Luteal Function Profile. *Submit minimum 1 mL serum aliquot in transfer tube from RED TOP OR SST for each day drawn. (Do not submit in SST) Freeze all samples, keep until finished and ship together frozen on ice packs ** P+7 testing requires three aliquots (Two - 1 mL, and One - 2mL minimum) Prepaid shipping kits available Call 402-390-0532 to order a kit Diagnosis is MANDATORY for all Patient and Insurance Billing. Please circle the appropriate Diagnosis. PEAK +7 PROGESTERONE** ESTRADIOL DATE/TIME DRAWN___________ INITIALS____ PEAK +9 PROGESTERONE* ESTRADIOL DATE/TIME DRAWN___________ INITIALS____ PEAK +11 PROGESTERONE* ESTRADIOL DATE/TIME DRAWN___________ INITIALS____ N93.8 N92.6 E28.9 E34.9 E34.8 E28.2 N94.3 EO3.9 Z13.29 Dysfunctional Uterine Bleed Irregular Cycles Luteal Phase Defect/Ovarian Dysfunction Endocrine Receptor Disorder Other Endocrine Disorders Polycystic Ovarian Syndrome PMS/PMDD Hypothyroidism, Unspecified Thyroid Disorder Screening ICD-10 Code___________________ Diagnosis_____________________
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