Health0 iagrtiCLabOratOryl nc. 0002442 -0168002 or. Morph P.13130anaciiiiitatily Mega GJA No. 490/100708 I CAP No. 7224971 I NH No. 1629209853 INSTRUCTIONS 1) please Min allol the yelew Ng Weed amain% tiding the clognosn code vecton at (Mum tenon of chit requeaston 21 Have the patient sin the Relent and Assignment ol Stoat; semen below 3) lea, Inc. will accept an Malone Demographic Sheet n sublets...le for Panne information provided it melees all required SIIIIIIPSPOI4 II I40-9 codes we Mt Part of your demographic sheet. please pr Me +copy of the Patient Problem List including al ICOJACM cabs For diagnoses. conditions. or symptoms. PhOtChins 10, <Rhea indohcluats aut hooted to order tests, should on), order tests that we intensely necessary and reasonable LAST FIRS1 0002442-0166002 LAST FIRST 0002442-0168002 MATION it last Name: Win Middle Initial: pmj„„11,1,Jt 1 1 1 1 1 1 1 4,1.j 1 1 1 1 1 City: IRAN: Cell/Home Insane: Work Phone: Email Address: Pip Code: Social In :Ltspir. hots i Weft ht:LAST LAST FIRST FIRST 0002412-0168002 00024C-0160002 UST FIRST 0002442-016600: LAST FIRST 0002442-0110002 SP. Arts Dr. Paw Ate 4487 Philbrook Squire San Diego, CA 92130 Dori!, Ph PECIMEN INFORMA Rowing Lab. Collection Date: * Phlebotomist's Initials an: dme of last dose: Phone am/pm Fasting:3g Set H's NO "IA sINSURANCE: Please attach a copy oF ROTH Skies et Patient's insurance card. Medicare Number: 0 SELF PAY: HDL Inc. will bill the patient. im Fr ASSIGNMENT OF BENEFITS Ai a mu:ten. Di I every reasonable effort to obtain reimbursement for ordered tests. I au • Tor, re HOI. Inf to re:eait to %led co ie. its carriers, and any insurance carrier or health plan providing medical benelits to me. any 'one motion that may be needed for claim purposes. I consent to submit my sample to SIDS . tor testing. I am making an assignment of Medicare. Medicaid. and/or insurance benefits to HDL Inc. ea to myInstance: I understand that it ray insurance company pays me dreg* for services rendered by SIDI.. Inc. I am responsible for forwarding such payment to HDL, Inc. I also understand that I am responsible for any de ductibse/copayrnent. as required by my plan. Important: Insurance regulations regime MX inc. to seekpap-rent. I Permit a copy of this authors/alias to be in place of the original. Gene& Informed Consent: If ordered by my ph vessel. I consent to haeng genetic analysis performed at the request ol my physician and the results of the analysts made toilet:410 my 4...Wolin 64Y results are solely used by my physician to obtain information for therapeutic a diagnostic purposes This signed request authorues Het Inc. to perform the test and deiced° the results to my medical practitioner No tests Other than those requested by my physician wit be performed. Patient Signature PIr an o B LOLP & HDLP oAI Lore/ mess IWtoe)-P(O Los-C RP-PLA2 h Frbdricon HEIL 2 Gelman-3 Homecysterna 13 Fin & Total Reverse T3 14 Free & Total 191 Testosterone Fres Ttstobletons IGF-1 sdLDL NT-pro BNP Clete ID: Phcoic ■ Date BAB 6/5 /15 KI cny Cortisol AspelnWorks Glucose Tolerance Test FSH Uric Acid Progesterone AO* e swan. Cyststrn-C Feria V Leiden Sterols tN Prothrornbin Mute& Onmee-3 Iron & II BC DHEA.S MTHFR Iron VII D SHBG 1St RBC Folios \Main 012 LDUC DPMP Leona Adrocriectr Apolpoproten A I 82172 0Apospaproten 8 82172 DH042 C Subclass 81664 ❑LOL.P 8 Hobe Ilsy Neal 83704 0 ONO massed refer 83695 0 sdiot.c 83700 Awes l rir=74?n::..rnn82565. Wor 84431 0 7/Isaiah:manes 83789. 82570 O fibrinogen 85384 Ohs Cfle 86141 0 lisiPLA, 83698 OMPO $3516 IrTIFFIFF.32777 83180 ❑FM/M CA OGIamst OHtneglotsn Sic ❑ sernecysteine O 84631 82726 82947 85036 83090 83525 ❑ ROC Fonts 82747. 25014 ❑Unc Acid 84550 O Vitae^ 6.r 82607 025 hydrcoevitamin D82652 Routine Pane s (see reverie fide for derails) *Ca Genotype 81401 OCYPX19 (Nem' Response) 81229 CI FaCtOr nekton 81241 0 MTHF8C6774 8.3129.9C MutatiOnS 81291 O Proihrombin Mutation 81240 OCYP2C9 ri •s1 8. MAGI chtscsao 8122781355 Earrillaill AillriErallilli r ung 70 ❑vs.A. total 84153 SH 844)3 O14.1 Free 844)1 O14 84436 BT3. free 13 64481 8.480 O Basic Metabolic Panel • Comp Metabolic Panel ❑ Complete Blood Count w/dIfferendel El Diabetes Prevention and Management Panel (DPMP) • Hepatic function Panel o Lipid Panel • Omega-3 and Omega-6 Fatty Acid Profile O Oral Glucose Tolerance Test (OGTT) O Renal Panel ❑ Noncholesterol Sterols & Stand' LI Thyroid Cascade asK, hisNli reflexes to )4. free 71. and Ti) LI Thyroid Panel (194.13. 14. and free T41 80048 80053 85025 80076 80061 82541, 82544 82542 Additional Tests On Back Please write the test name and COT code °Name. ONa Cltiame: CPT' CPT' faleigNOSI5 CODE(S) REQUIRED. PLEASE CHECK AU. CODES THAT APPLY. WRITE ADOOKINAL CODES IN THE YELLOW HIGHLIGHTED SECTION AT THE BOTTOM Of THIS FORM. The codes below are listed as a corMmience. This is not an allinClulive list. INIMICRIERNIM 011naertmuice. magnate ORPM•ftlifitaCiel, benign Jura:demos.% tantsecifed jitypenensive heart disease, n.µgnant Jlerpenensive Man Or benign. a/oMantracer. Dhhiptinenvve heart Or benign. w/ heart (elute DItypenentive heart dr. umpire w/o heart failure Danes& NO5 DChant pats unseen...0 Dub. name artery ]Coronary atherosclerosis due mulched logn OCardiovascutar disease. unspecified FASCVOI Diarnoly Nuance cardsnausibe disease Y17.49 Oltaalrfigratoss. moderate 263 0 0 Personal h. of tobacco use %Family hedoryischemic heart di V17.3. OOthe. 8 cornetts deectenoes Wit $121 266 2 0 liovtine annual health check-up J Carotid artery colusidenosts, wto infanta, 433.10Retarnin 0 deficiency 268 9 0 Long term (current) use of meacanons 3 Alf ial hbralloOn 427.3gOOsteoporosis.1405 713 CO OLOODDISOODON jAtnbroscletosts of ocher 'pentad arteries (non coroners/440 8 iCHspenhcarsterolernia 2724 [Ilion deficsency anerma. unspecified LI Athssrov.ltrunc vascular 2.12, 505 440.9 CI Pare hyeergiecendernignementighteetrinu272 1 0 rotatedekleaCy leternto ENO oatill&NUMMON.MITAIOLK OHyperhpetemu. rinsed 272 2 0 Memo& denciergy. unspecified istypothuicidism unsettled 244.9 °Hyped...Sena NO5 272.4 DArstmia. unspecified Additional Codes: . . _......... . . ijoiatietes meatus, n controaid rot 0 MOiabetes meatus. II untontnYkd 401 1 C 99ectel screening for dabetes meatus 401.9 OFTediabetes. abn glucose eisperglyceenia 401 00eCktrated/ampaired fasting glucose 10.7 160 Personal history of gestanOnal diabetes 402 11 0 rangy htucry of clobetes molten 40290 OHsperparaterchoidism. unspecified 413 9 0 HypoparalliwOdopt 746 500 Testicular hypefunown. NOS 424 01)14ormiser/enesocrine disorder. ttinpeOfted 414.6 ONututional deficiency 429 2 OPAalnutotion. severe 25000 D unspent's., disorder of metabolism 25002 D Screeerg for lied disorders v77 I Oinsulin resistance/ Dysmatabolic syndrome 79029 0 Obesity, unspeohea 790.21 BIONl a StIAPTOtAS. STATUS VI2 21 Of atque malaise. weakness. NOS V180 OMemon Loss 251.00 Oatrormat gat 252.1 Clad, ohcoortio4nat 257.2 0 Weight loss. atincrreal 259.9 ()Abnormal blood chemistry lab endings V12 00ther abnormal hndings of. blood tests 262 0900.4c 0 usa and abuse 272.9 OThionstotroPenia. unSPetiatd v7791 MENTAL NSOIMMS 277 7 00tpressen NOS. Peretove mot, 311.0 278.00 Chiba depressor duster, recurrent episode296 30 0Alzhenner's dr 331.0 780,79 INSPIRATORY 780 93 050e (Shortness of breath) 781.2 0 Dyspota. respratory Insuffiateer 7813 OCO4th 785 21 Disbnotmat meat troy 790 6 OSeelling. mats or lump in Chest 790.99 Otiose cheese. NO5 3053 Drama/ history of lung cancer V15.82 0Astestos hiposiae, pence/OH v700 SIMMOINIUMIN. v5889 IDGCROMenia CRINITOMMIArt 2209 0Screeneu for Prostate Cancer (MN 281.2 00evaltdP54 2819 OProstate Cancer 285.9 Diemen prostanc nmenroohy Mehl 287.5 786.05 786.09 786 2 793 19 786 6 518 89 V161 V1584 53021 V7644 "a," las.° 640 AO EFTA00305909