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Lab Order

This document is a lab order form from Dr. Erica Lee for patient Alisha Reason. It orders two tests: the NASH FibroSure test and an acute hepatitis test. The order form lists Alisha Reason's identifying and insurance information. Dr. Lee signed the form, authorizing the tests and release of medical information to the lab on March 1, 2023.

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mike reason
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Download as PDF, TXT or read online on Scribd
41 views

Lab Order

This document is a lab order form from Dr. Erica Lee for patient Alisha Reason. It orders two tests: the NASH FibroSure test and an acute hepatitis test. The order form lists Alisha Reason's identifying and insurance information. Dr. Lee signed the form, authorizing the tests and release of medical information to the lab on March 1, 2023.

Uploaded by

mike reason
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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LabCorp

For Lab Use COR EDI ORDER

Account #:04226435 Req #:47276297 Page1


Covina Patient Information
415 W Route 66
Reason, Alisha M
Glendora, CA 91470 2209 N White Ave Spc 16
(626)960-2326 Pomona, CA 91768-1500
(909)675-4024

Creation Date: 3/1/2023 08:26 PST Patient ID :ECLO-1387


Expected: 3/1/2023 DOB : 6/2/1984 Age :38 Sex :Female
Lab Reference #: Fasting:
Ref Physician: Erica Lee Guarantor :Self DOB : 6/2/1984
Ref Physician #: Alisha M Reason Phone : (909)675-4024
U.P.I.N: 2209 N White Ave Spc 16
Physician NPI :1013506740 Prepaid: Pomona, CA 91768-1500
Call Results to:
Fax Results to: STAT
Primary Ins:Self Secondary Ins: Tertiary Ins:
Alisha M Reason
2209 N White Ave Spc 16
Pomona, CA 91768-1500
(909)675-4024
DOB:6/2/1984
Policy #:90451760E
Group #:
Bill Code:DEFAULT
CITRUS VALLEY PHYSICIANS GROUP
Po Box 4939
Oceanside, CA 92052
Eligible:U
TEST CODE/DESCRIPTION DIAGNOSIS CODES
1) 550140 NASH FibroSure *R10.9,
*K76.0
2) 144000 Acute Hepatitis *R10.9,
*K76.0

Authorization - Please sign and date


I hereby authorize the release of medical information related to the services described hereon and authorize payment directly to Laboratory
Corporation of America. I agree to assume responsibility for payment of charges for laboratory services that are not covered by my healthcare
insurer.
Erica Lee 3/1/2023 8:26 AM

Patient Signature: Date: Physician Signature: Date:

Total Tests :2
Oper ID :amy.tecosky
Reason, Alisha M Reason, Alisha M Reason, Alisha M Reason, Alisha M
6/2/1984 3/1/2023 6/2/1984 3/1/2023 6/2/1984 3/1/2023 6/2/1984 3/1/2023
04226435 47276297 04226435 47276297 04226435 47276297 04226435 47276297
Reason, Alisha M Reason, Alisha M Reason, Alisha M Reason, Alisha M
6/2/1984 3/1/2023 6/2/1984 3/1/2023 6/2/1984 3/1/2023 6/2/1984 3/1/2023
04226435 47276297 04226435 47276297 04226435 47276297 04226435 47276297

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