EFTA00287148.pdf

N. eisensa vood,thfrAtioviv 211 -,.r3 V sage ii: linlooThrma.‘ ) 0800.2: gc:: la it: : ," 44 E 61th St io Mr iiii NY 10045 To find the nearest patientNe NYN service center, visit wvnv. 08231143092 D8231143092 08231143092 labcorp.com orcail 888- IABCORP(888-522-2677). 37 len 092-o D8231143092 08231143092 08231143092 08231143092 L RS2553-AEOREIL. YD Name (La*Fm* Sex Date:129th Collection fine Fasting CclectionDate Unnehrshol 44,4 Ores WO Day 48 ECK tOtE 20 0 No hrs_vol_ )4 1-7 MIEN) NIL) )S I I SPOICARE 17 INSURANCE lame (Las! First 1XIIIN 10170RD slur x /1-,,s flosotat Palters Stattz. (i In Patent O OhA-P859.1 ❑ Non -Pa ant IOW( IISPIRI CR :SCPTI ICISNA NC SKS C )CINNA Nins7Symptorns in iCGCM format in efcci at Da of porno* Pergnr //cf. 31-ReerPhozazis-virs- VETNAC /AETNA NON SAD ;WU METRO PLUS HPI q K(3;°I . V72 ft G') NYC— Nome of POliCy Molder (4 O41erom from patient) N ?Mar ININTI 111EALTONE1 AVM 7USI GRUNT Ineurenoe Caere LA C Inaumnce carser 3 Address of Policy Holder APT IRTAEI )61TAIN/AIT 1RI1E( )UNITED SHURE Ds R5 1 4 - 055C1 7 0. .1 ->s:fp pl.' CM Stab ZIP ARAI thANNA CARE-NY Groups c#2 17 .2_c2 0 Cr“ t OM" HEM MUM* AC PITS tan an= St sem Nan mum raomstuf of alga use arse Mead Nato teiMINN mines re non bt May areas me as sa that WO. u '— rRAPt )RAISER PiRRANC Insofar= Address Insurance Address. X Name of Insured Person Name of ',footed Person Ler.. Spits.) Relationship to Patient Rslatonship to Patient er to Determining Necessity of ABN COInpieben on reverse ffiiiikiceid State (Mpopt4 Nerve Employer Name Ofl.EATESTSIMOt7IDUALPROk CCV.06, NYS Ptrif;man's Provider It Work.," Comp nYea ootVf s2s-r 9-66 371044 I 17t4AblIgS/AltlabesiviI9Srh... O 0 it OZ-0 371061 I I COP144I0C1C/D/PlitOgriliCt... 00 ( r -Yr o 931? /6496e— 371195 I I ISH.LN)Pros 27110137 &Mr ok_r( ENDOCERvix 71 THROAT ; STOOL r uarram iJ MUHL *tot I Fs-trans, LCAS, tnde Sci O oL STD it OTHER SOURCE: 008649 Meth C Naval& CUtue t 87070 S.AT vrhopuNCroke no%tapCJI. VERSA PRIMP 04ARTOAMP ruin R WI140144. sanydimons .},}14}7/M t}liellEfSIMa ,a, '. n si 008482 FvnOPSCultureP 87101 ORGAN OR DISEASE PANELS ALPMABE CAUCOIABINATION TESTS L ALPNABENCAUCOIABINATiOti TESTS I 008334 Grater Cour*. Routre 1 87070 See, reverse tor components G A Rigte,(Gtee OAT 86140 006189 Monondcleosis Test. Ow, 86308 ea 008540 Gunn Stem 87206 006827 0 188132 GO 51149041041.814 fort to 322744 MAIHepatitis Panel 80074 Me 120766 . .4., •, CaSIMPRItelPei 88141 @ 884247 — R LpoProfile• r el.: i @ 322758 1409abolt Panel (8) 60048(D 0074 Carternuetine (Tegrelce) MSC@ Phenoteibital (Ltrinar) 80184 188139 611351 788014)8tb`szcep Melt* Panel (14) 800S3 ( 1 002139 — CEA wen rig) 007401 Phenytoin (Orland/1e) sows CD 180810 87070 303754 Electrolyte Panel Booed@ 001065 Cholesterol. Total 82485 @ 001024 Phosphorus 84100 182949 Ocall Blood, Fecal. IA 82274 nrn o.. 82565 Eg 322755 Hoak RUI1C191 Panel (7) 800261g) 001180 Potassium 84132 008623 One and Parasites 001370 — Creabrine 008144 Stool Culture } e81ro~As 3037 Panel seem@ 007385 80162 @ 004455 Prceactin 'sue Goss. Dgoxin (Limon) 236010 UFA Panel ALOLniCe. Rade 80061@ 004515 E add 82870@ 01 84153/G0103 008169 Throes SIE_ Nemo)* Saw UK &OLP. 87081 00 008342 lta glesprearyCubse.t87070 221010 Upid Panel yertONDL Rao WWI® 304698, Kwraei 82728 ® 1947 - PSA. Free: Total Ratio' :I ' 349926 Uticl Pans tonna eons BOWL® 028480 Fs4 a d ui ... am (ig 005199 Prothorrbn Tat (PIMA 85810 (E) 7 UM* Cullum. Floutinei 87896 Renal Function Panel 03069 0011}5WT 82977 @ 020321 _ PT end Pa Acevated eras EMT°. CNIY 82947e 005207 PT7 Activated 85730® 180039 Nuehrab• Vegnitis (VO4) Me 001818 - Glucose. Pasma NOM w Pt 85025 est2 (g) Wer302. -10r80238028/9itis Fade. e3431 ig) 180021 546 /444094910494.4401844 7,0 001032 &cost SCUM &KISS Vagina*. NM ;MOM 028142 CBC to Claw Plt 82692 ( i), 180060 asoi4e 034556 U3R314.804/16als ?way, Pa70.3 C) °°°022 APP 180055 C Itual 4C ;Wait KM 8148192) 005068 Hintatoult 850,8 (0 ce4415 pc°. en soscull 84782 c) 006197 _ Rubella Antibodies, KID 88782® 005041 Honvglotel 180010 Grate 514IXON Polk, MA anti peg c ) 001925 th-,-,) 005215 Sod Rate. Westenyen 85652 C) 005249 Pleat Count 85049 HDL Cholesterol 83718 ,.:.` 001198 _Sedum 84295 183194 g) 183160 Chlawder,onoxera ggil 005033 RBCCOUn1 seggi (a) 0errp45 01 3 moglobln A1c 83036 leo 0 /449771 Fins efixtAAriftaly, iv gang @ °°4226 _ Testosterone. Total 84403 lajl 180089 OHS 941q9281184 8005 AMMO 005025 Mt Cant 85048 ing ,,., 070301 Tease/ Warcettlitten 84403 15179 Onaentracta ARC Co.nt egtli Mil 036495 Hop B Surface Mbbody 436706 ME..4 — 188056 it9V1 2. NM $782102) @ 007338 Theophylline 443i98 ) 87861 ALPHABETICALCOMBiti ADON TESTS 038510 He943 Surface Antigen 87340 88052 Waives vegna tlAk 0 001149 3" °" Thcm acmafta° ;•84436€) -••^41) _ 006049 ABO and An raw., we et 144065 1/3•4514bAbVerlicaem 093c0 — t Thyme/fn. (}4 001081 AHLrnin 42040 An 083924 HIV41/02 Antitcdes' 910343 Chronc Kidney Dsease Report 86703 0 MLR., 001974 TAT 84439: 910385 Cardwascetar NO<ASSesvnenllielX1 001107 Alkaline Phosphates° 84075 reigli 1.02449b:des* 41018.185703 ID — t ponnsemnin coxed, r,... 082945 — Nast order art 36194E-1pd Cascade C015445 ALT (SGPT) sue° i,.n.) 180836 Hp7ifintkaa Breath 83013 6842474MR upoProlie Alpe panel) 001396 Arrefese a2150 001172 _ _ Triglycerides 844781g) 0974 Lan Bone Density Report 180704 SW Antigen enge © 002188 .. TrIlOdOthyronlne (Ts) 86480® 164855 AnInucloar mtioodres 86038 0 H t . ID / Suscoptibil at Additional Chargf 84450 0 001321 ardIEC ms miww n mw 001156 74Uputke 84479® • = Confirmation at 001123 '• (SOOT) ' I Charge 00081 sndFaye "` gr. cD 00111 83515 004259 • N. 3rd generagon 84443® = Also available wish Aptinta urine Caeeal lalormillonlCornetents 001099 EiSka). Total n 82247m 351948 — LipidCescede =4.4.4@5 00t Acid 84550@ 001040 BUN 84520@ 007708 Lithium (Eakalith) 80178 00 . LAO nnalysts 8 m4A= 81803 la) 111016 Calcium 82310 'el f I 1537 ..,88,,,. .• 83735 fn ‘,Q8 _ 11aIrit D. 25-Hydroxy 82306 ne la Mini I . •• II 'AILS I . ..auterset sIiiii.11011WMKT metiteionfunti41}41.1;141 0.112802.61842419.11321111116811134Aillailll EFTA00287148  wocia.z,on rterreQu ri it :t I-8x pLabCor I er .6 44 E ,5'etil St Ne~ 6 meow NV 10065 ID Call LI Mail whrdiselwww 6anwari OlØ To find the nearest patient /NM service center, visit YAW EGU3114:3092 ECU31143092 EGU31143092 1313001110001°r tel el» 31143092-0 LABCORP (888-522-2677). EG1131143092 EGU31143092 EC1131143092 EGU31143092 AtzsSI-NERRELL. MO rtRAQIINYM(1.881.ffillMq Sex Debt otEllith Cole/ton11mo fasting Celiac/ice Dale Urine hreNol CHECK Q1 AN I-I FRTIENT BILL Err r URN PhyRdan's 11A5! It : Tes uo eY:oit/ °AY VA e OS C 1 MEDICARE ram= Pabonrs II t INSUPANCE OXFAPt )OXFORD SNarno (Last. FirR) Flomtai Pawns Stats O lePatlem 1:l Oui-Ptere O Non-Pant AETNA< )AETNA MU WO NARA( )MAGNA CARE-AV AMITE( )UNITED ALTACRE P,rn"-'1`41, totefff- Gty CGCtf< )CILIA NC ANC C CIESMC >CIGNA NYC 1 ct Pc!rcy ,la~ (if «err from Paban4 ACCRA )AARP MFDICAPI UNRF6( )OAR ~nee Came' ti t invAanoe Gainer • AETNA >METRO PLUS NPL ID e MACMCC >HNC-MEDICARE C ID. 3 5.1 4 - 1a.C5 EMS( )EMPIRE KBE CR Gimp MAUR( )MLTAREPUD • 2.72.G.Q.c C1 . Group • howanwriemmdmeldhlemmyenblediøeneNeefteedheldoodatird~b~n MALCIC )NALC Inman» ~Wee • t enement, ~roes IMMs» max blryirepopaldellowlorkienterAmforg Air Yale Hems allowed Pan 'Nome Stout Ponca Reialenehlp to PrIers inelefisomhip lo Patient Rdet tO Delerining 01 A28 Completion on raffle EMOI0Y•r NUM ; &clover Nam ;It Medicaid SUM ~an% Rear • I -arm 1:1No 371044 t J LynePA(I9GiM1+B≥besi≥(29GyM... 371068 t 1 CHP14+Fe+COC/D/P1t+M9+TIBC+... : ENDOCERY0( C ~OAT 371195 t 1 FSWitiltfrog STOCII. r tmeninA 5004.34 t Estroner LUIS, Endo Sci ~el SOURCE' • 008649 Aerobic Bacteria Coon t 87070 • .IrVLw C1XMT•"eR wLx.1YRIREN 9 085 __ _ 99:261 008482 6/Ny4CA:wet 87101 AL•tl'-E7ICALCeN:INATIeNTEST$ 038334 evenai Cu.*.Rams I 87070 Seeroversel• 001016 Calcaum 82310 006189 Mcnont.ocose7est, Oval 85338 Be 008540 commit, any 322744 Acute Hepates Panel 80074 GE — :ex: e 07011 Q884247 188132 01p 8818614 NAA 322758 322000 Basic Melab011o Panel (8) was 071, Comp Metaboac Panel (14)60063e, 006627 120786 efioNI"Oat tilnehelM5361 86140 80141 @ 0071323 _ WAR LtaoProtte4 Phenoberblel (Umber) 80184@ 181139 180810 h BBleptattA4Raring ,....,FininecryCunnt 87070 303754 Electrolyte panel 8005,G) 007419 ~tug, nopolt.45.. Boat® 007401 _ PhertyMin (Dilentin. ) ECM® 001024 ,___ Phosphorus e4103® 182949 Oocult Blood, Fault, IA 82274 322750 Hepabc Fifteen Panel (7) soma/ 003139 9..E-1‘_ ..._. . . ...... C>38823 Ova and Parasites mn 3°3750 __, Lipid Panel WeellE1 001086 eemitemeat'iåii 82485 001100 ._ Potemkin', 84132@ ° 84146@ 008144 Stool Culture 1 t, .7%; er 1 2 / 's 235010 _ li pid pnhtt pupo. Rao an t i', 001370 ~St 82565 @ 005405 — Prolactin 801e2 ( i 010342 PSA 84153630103@ 008189 Th stZ it a lr' Gra7", ,,' 47' t 87081 221010 ,_ WO Panel wiletel. Rain 000el (El 0023135 DIPOOOP19$ili ) -— 008342 W*willaømto9CAtatrom 004515 Eitick1 8267,0 Gi 480947 — PSA, Free: Total Ratio' : 41r, C 343925 _ tØ panal 04443. 00~ eoz 87086 6847 wino Oita Routeet 341946 IØ Cascade 1v..1« L. 004598 nit ems 0) 005199 - Nehrcntin Tim(Plytle PTTActimed 85610@ an @ 353675 _ Ad [mina 4, o BA so 4...e Wee EIE onao FinlandLit ...., ux., Co 020321 Fiend llEe Renal Function Panel C PTT Achvated 85730® 80039 NuSwatneolnes (TO) 001958 GOT 84T7 X 006207 186621 tiSientd 918P0119(9) 006502 Rheumated Mints fact,. 864310 V 001818 etcomplisin8 !:W47 005009 C8Cw,11w 13 Pit 85025 88592 @ 180080 8•3444111~, NM MOM ,_... 028142 CLICSoCew Pll 86027(a 001032 5100098, 98600 ... , SP47. 006197 Rubella AnUsodies, IgG 86762 @ 180055 ct0eew8C918a1LIYA mio 006068 Hernidooll 85014 asone) caws 004416 103,11131d01$661~0) 84703 @ 8c6.8,80402*0788 84702 ® 1812.10 "Stmeas Prils. WA 87481B6) 005215 _ Sod Rate. Westergren 85652 (Z) 005041 Ityncolotil 183194 014884bGtxutl6W Fisj 001198 "944 84295 @ 005249 Plaledel Count asosn ) 001925 HDL Cholesterol 83718® 183160 ebNirvI ~no 004228 r Testosterone. Total 84403 @ 006033 NBC Curd 85041BD 001453 HoniNdobin Al c 83038 @ 180089 GeMtl MytOrttla S8at• 87794(4 ,--, 070001 — Terkeleknakroesenitren 84403E 005025 WOG Count 85048 V 006734 Hep A Antibody. hp 88709%LW 188056 HSV I II 2. NM $175211(e) 007336 15173 Dikterreallbtal W8C Coss eø1 v 006395 HepE1Surlace Antibody 86706® Thoophyline 80198 88052 74:Roncess tit» inse, „__, 330015 howitmattiProile =~4( .3 Al Hq'ETICAUp1.i:INATIrNTE5T5 006510 H00862592 Mogen 87340 Mi r, 006049 P.130 and Rh MA NBA v 001149 Thmcgiste (T.) 84436 Co n""'••• "'" 144065 HCVAMifithASTe- ficalen 86803 QM) C.hroric Kidney Disease Repo« 001081 PEbumn 001974 _ ToyindnoR. Frio 54439 E CodirmairFlaPaemensvi116re 42444R 063824 En W1/02 Arthodies* 98703 @ 001107 — Make Phosphate's 84075lOW 082345 7.pikkeSerwingCascade =,.... «Wit 631946•UpldCando 001545 ALT (SORT) 162222 149.1332Mtlxdo • • NYONLY86703@ 001172 Trloycorkles 84478 1g) 84460® 001396 Amylase 82750 it...E, 100636 HpylohUrea Brea2, 83013 (a t) 002188 Tr0000tercr ece 0.4 84490(&i 164855 — Anlinudear es twee@ 180764 HOYSodS1031 Anti9on 87336® 001156- —. T.Uptake 84479® 001123 Iron and ISC 84443® corm wantioN~a AST (SOOT) saso(Z) 001321 ::.4e. X® 1304259 TS1I.3rd generation 000810 on e ; 44 e ,44 m c ?: CE. 001115 WM 83615 (W 001057 U6e Acid 14550 ( I 001099 Blkubin, Taal 82247@ 007706 Lithium (Eskalilh4) 80178 @I 003038 udnatis a ",=, en ow (;;) 1010 BUN 84520 G 1537 flask" 8373s ( i. ‘1161950 Vitamin 0,25-Hydroxy 6.2308@t EFTA00287149  p Isht ar , koodso%f'1ilTti$WT'1ti' e.:4G;rw v r 1-9X O Cal ......4................ SIMMer — 44 E 67th St i MC O MeA patientHeilim NY I0065 . .— ..m. • . . ••••• • ••• . To find the nearest NYN service center, visit VAWI. labcoip.com or call 888- SBC31143092 EBC31143092 EBC31143092 utecoftp 0388.522-267n 31143092-0 EBC31143092 EBC31143092 EBC31143092 EBC31143092 ;11; LE QIIE A62553-HERPEI L. WO ( Sex Daleolarth Co:lector. Time Easing Cone:bon Dale Urns Maim( Paberd—slogielNern00.8gtArstM0 voi CHECK ow nos-it-DJ Tr-Me v.Y M ..)05 DAY ' ia ma O yes mo