Laboratory Requisition Form

718 Teaneck Road Requisition#:2480000056

Teaneck, NJ - 07666

Patient Information
Name : A T. Williams MRN Number : M000001501
Gender/DOB : Male | 01/01/1990 | 32Y Visit Date/Time : 06/04/2022 7:45 PM
Address : 3000 OLD CANTON RD, Jackson, MS - 39216 Episode Number : A000000002282
Email : balachandar.p@tvsnext.io Cell : (234) 324-3243

Insurance Information
Relationship : Father Relationship : Uncle
Subscriber Karthick Davis Subscriber Name : Karthick Testeight
Name : Secondary Name : AARP - Medigap Plan
Primary Name : AARP - Medigap Plan Address : 423 East 23rd Street, New York, New
Address : 423 East 23rd Street, New York, New York - York - 10010
10010 Policy Number : 8764654738383
Policy Number : 9876543210

Worker’s Date of Injury :

Comp :

Ordering Provider
Name : Marshall D. Webster Facility Name : HNMC Practice Management
NPI : 1003000415 Facility Address : 718 Teaneck Road,Teaneck,New Jersey-
07666
Phone : (655) 645-4323

Diagnosis Code
ICD Code Description ICD Code Description
C85.10 Unspecified B-cell lymphoma, unspecified E11.9 Type 2 diabetes mellitus without
site complications
E10.9 Type 1 diabetes mellitus without
complications

Order Information
Order Code Order Description Specimen Fasting Collection Date/Time
Requirement
CBD CBC w/Differential N N 06/20/2022 9:08 AM
NH3 Ammonia N N 06/20/2022 12:00 PM
BC5 Blood Culture - 2nd site Y N 06/21/2022 5:27 PM
TP Total Protein (Blood) Y N 06/21/2022 5:27 PM
CBC Complete Blood Count Y N 06/21/2022 5:27 PM

Guarantor Information Emergency Contact Information

Relationship : Self Relationship : Uncle
Name : A T. Williams Name : Emergency C. Lab
Gender/DOB : Male | 01/01/1990 Address : 3333 Broadway, New York, New York -
Address : 3000 OLD CANTON RD, Jackson, Mississippi - 10031
39216 Cell/Phone : (876) 543-2908
Cell/Phone : (234) 324-3243

Authorization - Please sign and Date

I hereby authorize the release of medical information related to the services described hereon and authorize payment directly to Holy
Name. I agree to assume responsibility for payment of charges for laboraatory services that are not covered by my healthcare insurer.

MR#: M000001501 Page 1 of 2 printed on 06/23/2022

Episode#: A000000002282
 Laboratory Requisition Form
718 Teaneck Road Requisition#:2480000056
Teaneck, NJ - 07666

Patient Signature : Date:

Provider Signature : Date:

MR#: M000001501 Page 2 of 2 printed on 06/23/2022

Episode#: A000000002282