Cholesterol, Triglycerides, HDL, LDL, Cholesterol/HDL Ratio

Na, K, Cl, CO2, Ca, Creatinine, Glucose, BUN Na, K, CO2, Creatinine, Glucose, BUN, Alk. Phos., Albumin, Total Bilirubin, Total Protein, AST, ALT, Calcium

Albumin, Alk. Phos., ALT, AST, Total Bilirubin, Direct Bilirubin, Total Protein

Na, K, Cl, CO2 Na, K, Cl, CO2, Ca, Creatinine, Glucose, BUN, Albumin, Phosphorus

RENAL FUNCTION PANELELECTROLYTE PANELHEPATIC FUNCTION BASIC METABOLIC COMPREHENSIVE METABOLICLIPID PANEL

PATIENT INFORMATION

INSURANCE INFORMATION

TESTS AND PROFILES

ICD-10 DX CODES

CUSTOM PROFILES AND ADDITIONAL INSTRUCTIONS

ADDRESS

POLICY NUMBER

PATIENT RELATIONSHIP TO INSURED:

DATE OF BIRTH (MM/DD/YYYY)

FIRST NAME

CITY

SEX

MIDDLE INITIAL

STATE

SOCIAL SECURITY NUMBER

ZIP

PHONE (H)

SELF SPOUSE DEPENDANT

PATIENT SIGN HEREI hereby assign all rights and benefits under my health plan and all rights and obligations that I and my dependents have under my health plan to Genesis Diagnostics, its assigned affiliates and their authorized representatives for laboratory services furnished to meby Genesis Diagnostics. I irrevocably designate, authorize and appoint Genesis Diagnostics or its assigned affiliates and their authorized representatives as my true and lawful attorney-in-fact for the purpose of submitting my claims, obtain a copy of my health plandocument and SPD and pursuing any request, disclosure, appeal, litigation or other remedies in accordance with the benefits and rights under my health plan and in accordance with any federal or state laws. If my health plan fails to abide by my authorization andmakes payment directly to me, I agree to endorse the insurance check and forward it to Genesis Diagnostics immediately upon receipt. I hereby authorize Genesis Diagnostics, its assigned affiliates and authorized representatives to contact me or my health plan/administrator for billing or payment purposes by phone, text message, or email with the contact information that I have provided to Genesis Diagnostics, in compliance with federal and state laws. Genesis Diagnostics, its assigned affiliates and their authorizedrepresentatives may release to my health plan, their plan administrator, my employer and my authorized representative my personal health information for the purpose of procuring payment of my Genesis Diagnostic laboratory and toxicology claims. I understandacceptance of insurance does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance

STOP

ORDERING PHYSICIAN SIGN HERESTOP

Signature of Patient or Patient Representative / Relationship to Patient Date

Ordering Physician Signature Date

Creatinine, Urine

Physician must only order tests that are medically necessary for the diagnosis or treatment of a patient.

CLIA # 39D1099562 | 900 Town Center Dr, Ste H50, Langhorne, PA 19047TEL: (267) 212-2000 | FAX: (267) 212-2005 | www.genesisdx.com

Date Collected:_____________ Time Collected: _________________

LAST NAME

Commercial Medicare Medicaid Bill Patient Bill Client W/C (Date of injury):_____________

NAME OF INSURED (IF DIFFERENT FROM PATIENT)

PRIMARY INSURANCE NAME AND PLAN

EMPLOYER/GROUP NAME

(1SST) (1SST) (1SST) (1SST) (1SST) (1SST)

Please ensure Custom Panel has been established on new account form. Please refer to back of this form for a listing of tests in each panel. By ordering the custom profile on file, the ordering physician acknowledges, by signing below, laboratory tests being ordered are reasonable and necessary for the named patient. The ordering physician understands that they may change the custom profile on a case-by-case basis, by making their testing preferences clear in the space below.

ORDERING PHYSICIAN INFORMATION

123456__________

123456__________

123456__________

123456__________

123456__________

123456__________

DIAGNOSTIC PANEL*

Hep. B surface Ag w/Conf. S

HDL-Cholesterol S

HCG, Qual. S

Rheumatoid Factor S

Anemia Screen 1L; 1S Hep. B surface Ab, IgG S

Hemoglobin A1c L

Estradiol S

RPR S

CardioGenesisDXTM Panel 2S; 2L Hep. C Ab, IgG S

Homocysteine S

FSH S

Rubella Ab, IgG S

Protein/Creatinine Panel, Urine 1UCHEMISTRY

Iron, Total S

LH S

VZV Ab, IgG S

Diabetes Screen 1L; 1S; 1U Albumin S

LDL, direct S

Progesterone S

Thyroglobulin Ab S Alkaline Phos. S

Lipase

Lp-PLA2 (PLAC)

SS

Prolactin S

Thyroid Peroxidase Ab S Hormone Screen, Female 1S ALT S

Magnesium

S

PTH Intact S

MICROBIOLOGY Hormone Screen, Male 1S AST S

Potassium, serum

S

SHBG S

C&S, Urine U Health Screen, Female 2L; 2S; 1U

Amylase, serum S Ammonia L

Prealbumin

S

T3, Free S

Occult Blood, Stool ST Health Screen, Male 2L; 2S; 1U

Apolipoprotein A1 S

Protein, Total S

T3, Total S

URINE Hepatitis Panel 1S

Apolipoprotein B S

S

Sodium S

T3 UptakeT3, Reverse

S

Microalbumin U Hepatitis Panel, Acute 1S

Bilirubin, Direct S

Triglyceride S

T4, Free

SS

Creatinine, Urine U Microalbumin Panel 1U

Bilirubin, Total S

Transferrin S

Testosterone, Total S

Total Protein, Urine U Obstetric Panel 3L; 2S

BUN S

Uric Acid, serum S

TSH (Hypersensitive) S

Urinalysis, Complete U Rheumatoid Evaluation Panel 1S; 1L

B-Type Natriuretic Peptide L

Vitamin D 25 - Hydroxy S

TSH w/r T4, Free S

Urinalysis w/r Culture U STD Panel 1S; 1U

Calcium S

Vitamin B12 SIMMUNOLOGY

TOXICOLOGY Thyroid Panel 1S Carbon Dioxide (CO2) S

HEMATOLOGY

Antistreptolysin O S

Digoxin R 1S Chloride (Cl), serum S

CBC w/Auto Diff L

CRP (High Sensitivity) SC-Reactive Protein S

Lithium S 1S Cholesterol S

CBC wo/Auto Diff L

Phenytoin R 1S Creatine Kinase S

Hemoglobin & Hematocrit L

Valproic Acid R Testerone Free & Total Panel 1S Creatinine, serum S

Sedimentation Rate (ESR) L

Drugs of Abuse (12) UHIV SCREENING

HEPATITIS SCREENING

Cystatin C S

Reticulocyte Count L

TUMOR MARKERS HIV 1/2 Ab/Ag Combo Screen S Ferritin S

PT/INR B

HSV 1 IgG AFP SHEPATITIS SCREENING Folic Acid (Folate) S

APTT B

HSV 2 IgG

SCEA S

Hep. A

Ab, IgM S

Fasting Blood Sugar G

ENDOCRINOLOGY

Lyme

Ab,

Total

S

PSA, Total S Hep.

A

Abs,

Total S

GGT S

Cortisol, Total S

Measles

Ab, IgG

S

PSA, Free & Total S Hep. B Core, IgM S

Glucose, serum S

DHEA-S S

S

Hep. B Core, Total S

GlycoMark® S

βHCG, Quant. S

Mumps Ab, IgG S Other _________________

Other _________________

Lipoprotein (A)

FORMREQ

001-REV

04232019NMS

RedTop

G GrayTop

LavenderTop

SST Tube

S Blue Top

B U Urine StoolST 24hrU 24 Hour Urine Container

SwabSWRL

Protein/Creatinine, 24Hr Urine

Uric Acid, SerumUrinalysis CompleteVitamin B12Vitamin D, 25-Hydroxy

Ethyl Alcohol

Lp-PLA2 (PLAC)

Lp-PLA2 (PLAC)

6-MAM

Lp-PLA2 (PLAC)

Lipoprotein (A)

Lipoprotein (A)

Protein/Creatinine Panel, Urine - 1U

1 24hrU

- 2S; 2L

*Each class of drug can be ordered individually