Lab Form_PMS Series Requisition Form PMS

User Manual: LabForm_PMS--Series-Requisition

Open the PDF directly: View PDF .
Page Count: 1

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

CLIA # 28D043756 Thomas W. Hilgers M.D. Laboratory Director

PATIENT INFORMATION

Name (Last, First)________________________________________________ Date of Birth____/____/_______

Address________________________________________________________ Phone_____-_____-_______ Gender MALE / FEMALE

PPVI Account #____________________ *****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____

PEAK +7 PROGESTERONE**

ESTRADIOL DATE/TIME DRAWN___________ INITIALS____

PEAK +9 PROGESTERONE*

ESTRADIOL DATE/TIME DRAWN___________ INITIALS____

PEAK +11 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.

N93.8 Dysfunctional Uterine Bleed

N92.6 Irregular Cycles

E28.9 Luteal Phase Defect/Ovarian

Dysfunction

E34.9 Endocrine Receptor Disorder

E34.8 Other Endocrine Disorders

E28.2 Polycystic Ovarian Syndrome

N94.3 PMS/PMDD

EO3.9 Hypothyroidism, Unspecified

Z13.29 Thyroid Disorder Screening

ICD-10 Code___________________

Diagnosis_____________________