Doctors Place
Date of Collection_______________
Time of Collection_______________
Your Address Here
Date:_________________________
SWML Number_________________
1342 Bell Ave, Suite 3C
Tustin, CA 92780
Tel: (949) 581 – 1181 FAX: (714) 258 - 1114
Patient’s Name Last
First
Please print information correctly, otherwise the Doctor/Client account would be billed
MI
Date of Birth
Gender
Fasting  Non-Fasting 
Male  Female 
Patient’s Address
City
State
Referring Physician Name
Referring Physician Tel.
Zip Code
Patient’s Phone Number
Fax to:
Bill To: PATIENT 
CLIENT 
INS. 
MEDI-CAL 
MEDI-CARE 
CASH 
For patients paying with Ins. Medi-Cal and Medicare, please attach copy of card. For Medicare patients, medical
necessity is required for all tests.
I hereby have read the AUTHORIZATION statement on the back of this requisition and understand that will be
responsible for the payment:
Signature of patient: X________________________________________
PROFILES
CPT #
 Chem 50
PANEL
L
 Chem 40
PANEL
 Chem 30
PANEL
 Chem 20A
PANEL
 Chem 10
PANEL
 Comp.
80053
……Metabolic
 Basic.
80048
…..Metabolic
 Electrolytes
80051
 Lipid Panel*
80061
 Renal Function
80069
 Hepatic
80076
……Function
 Hormone
PANEL
……(Female)
 Anemia
PANEL
 DM I
PANEL
 DM II
PANEL
 Menstrual
PANEL
……Irregular
 PIT Panel
PANEL
 Pre Op Panel
PANEL
COAGULATION (BLUE)
 PT-INR*
85610
 PTT*
85730
 Fibrinogen
85384
SEROLOGY (SST)
 RPR-Routine*
86592
 HIV ½ AB*
86703
 CRP
86140
MICROBIOLOGY
 Beta Strep
87081
…..(Throat)
 Urine Culture*
87086
 Throat
87070
…../Resp/Culture
 Occult Blood*
82270
X__________
 Urinalysis
81000
(w/Reflex to culture)
 Urinalysis
(w/Reflex to culture)
 Urinalysis (w/o
Micro)
 Gram Stain
8100
81002
87205
INDIVIDUAL TESTS
CPT #
DX/ICD-9 Symptoms Required
 STAT
INDIVIDUAL TESTS
CPT#
L
L
L






84439
82947
83036
82977
83090
86677
S
S
L
S
S
S
OTHER REQUESTS
L
 HDL*
83718
S
L
S
S




83540
83721
83002
83690
S
S
S
S
S
S
S
S
S
 Wet Mount
87210
 Ova & Parasite
87177
HEMATOLOGY (LAV)
 CBC, Diff, & PLTS *
85025
 CBC, W/Manual Diff
85007/85027
 HGB/HCT*
85018/85014
S
 ESR (Sedrate)*
S
S
S
S
 ABO/RH
S
 Ammonia
82140
G
 Magnesium
83735
S
S
L 2S
L 2S
2S




B2 Microglobulin
Beta hCG/Qual
Beta hCG/Quant*
Bil Total & Direct
82232
84703
84702
82247/82248
S
S
S
S




Mono Test
Phenobarbital
Potassium
Progesterone
86308
80184
84132
84144
S
S
S
S
L 2S
LBU
SW












Bil Total
Bil Direct
BUN
ProBNP
Calcium
CEA*
Cholesterol*
CK-MB
CPK
Cortisol
Creatinine
CRP Hs
82247
82248
84520
83880
82310
82378
82465
82553
82550
82533
82565
86141
S
S
S
S
S
S
S
S
S
S
S
S












Prolactin
PSA Screen*
Phosphorus
RF Qual
SGOT/AST
SGPT/ALT
T-3 Total
T-Uptake
T-4*
Tegretol
Testosterone
Triglyceride
84146
84153
84100
86431
84450
84460
84480
84479
84436
80156
84403
84478
S
S
S
S
S
S
S
S
S
S
S
S
U
SW
 C-Peptide
 Digoxin*
84681
80162
S
S
 TSH*
 Transferrin
84443
84466
S
S
 Dilantin (Phenytoin)
80185
S
 Troponin/T(quant)
84484
S
 Estradiol
82670
S
 TIBC*
83550
S
 Ferritin*
82728
S
 Uric Acid
84550
S
 Folate
82746
S
82575
US
 FSH
83001
S
82043
U
 FT3
84481
S
 Urine Creatinine
……Clear
 Urine Microalbumin
……(24hr)
 Vitamin B-12
82607
S
Draw Fee: CPT (36415)
 Fructosamine
82985
S
 Vit D, 25 OH
82307
S
 YES
S
B
B
B
S
S
S
U
U
U
 Amylase
 ANA-EIA
85651
86900/86901
INDIVIDUAL TESTS
82150
86039
ST
FT4 *
Glucose *
Glyco HGB (A1C)*
GGTP*
Homocysteine
H-Pylori lgG
Iron
LDL Direct
LH
Lipase
DID YOU REMEMBER TO WRITE
YOUR DIAGNOSIS CODE?
Drawn By:
When ordering tests for Medicare patients, please order tests that are medically necessary for DX and/ or treatment of the patients, rather than for screening the patients.
*LIMITED COVERAGE TEST, MEDICAL NECESSITY ICD-9 OR ABN REQUIRED
SPECIMEN CODES:
B = Blue Top
P=Plasma
BI = Biopsy
S=SST
F=Frozen
SL=Slide
G=Green
ST=Stool
GY = Gray
U=Urine
L=Lavender
 NO
Patient Name:
Identification Number:
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
NOTE: If Medicare and other medical plans do not pay for the laboratory test(s) below, you may have to pay. Medicare dose not pay for everything, even some care that you
or your health care provider have good reason to think you need. We expect Medicare may not pay for the laboratory test(s) below.
Laboratory Test(s)
Reason Medicare May Not Pay:
Estimated Cost:
WHAT YOU NEED TO DO NOW:



Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the laboratory test(s) listed above.
NOTE: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
OPTIONS: CHECK ONLY ONE BOX. WE CANNOT CHOOSE A BOX FOR YOU.
 OPTION 1.
I want the laboratory test(s) listed above. You may ask to be paid now, but i also want medicare billed for an official decision on payment, which is set to me on a medicare
summary notice (msn). I understand that if medicare doesn’t pay, i am responsible for payment, but i can appeal to medicare by following the directions on the msn. If medicare does pay, you will
refund any payments i made to you, less co-pays or deductible.
 OPTION 2. I want the laboratory test(s) listed above. I understand with this choice, I am not responsible for payment, and I cannot appeal if Medicare is not billed.
 OPTION 3. I don’t want the laboratory test(s) listed above. I understand with this choice, I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
ADDITIONAL INFORMATION:________________________________________________________________
This notice give our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing
below means that you have received and understand this notice. You also receive a copy.
Signature:
Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this
information collection is estimated to average 7 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate or suggestions for improving this form, please write to: CMS, 7500 security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
PANEL COMPONENTS
 Chem 50
PANEL
 Cardiopanel-07
(Comp. Met, FT4, FT3, TSH, Lipid panel, GGT,
Phos, CBC)
 Chem 40
PANEL
(Chem50, Homocys, Mg, BNP, CPK)
(Comp.Met.panel, FT4, FT3,TSH,LIPID PANEL,
GGT, Phos)
 Chem 30
PANEL
(Vit B-12, Folate, Ferritin, Iron)
(Comp.Met.panel,LIPID PANEL, GGT, Phos)
(CBC w/diff, PT, PTT, UA)
 Chem 20A
(Comp.Met.Panel, GGT, Phos)
PANEL
 Chem 10
PANEL
(BUN, CA, Na, K, Cl, CO2, Creat, Glu, Phos, GGT)
 Comp. Metabolic Panel
80053
(TP, Alb, Na, BUN, T-Bil, K, A/G Ratio, Creat, AST,
Cl, Glu, BUN/CREAT, ALT, CO2, Ca, ALP)
 Basic Metabolic Panel
80048
(CA, CO2, Cl, Creat, Glu, K, Na, BUN)
 Electrolytes
(CO2, Cl, K, Na)
 Lipid Panel
(Chol, Trig, HDL, Chol/HDL)
80051
 Renal Function Panel
80069
 Anemia Panel
 PreOp
COMMONLY USED DIAGNOSES CODES
PANEL
PANEL
PANEL
 DM I
PANEL
(Comp Metabolic, Fructosamine, *HgB A1C
Glycomark, *Magnesium Serum, VAP, CRP-HS
Cardiac)
 DM II
PANEL
(Comp Metabolic, *HgB A1C, Fructosamine, CPeptide, Glycomark, *Magnesium Serum, VAP,
CRP HS Cardiac, Uric Acid)
 Menstrual Irregularity
PANEL
(LH, (Luteinizing Hormone), FSH, Free
Testosterone, Sex Hormone Binding Gloubulin)
 Menstrual Irregularity
PANEL
(Growth Hormone, IGF-1 (ESOTERIX), *TSH3, *T3
rd
Free, *T4 Free, Estradiol 3 Generation, Prolactin,
Free Testostrone (ESOTERIX), LH, FSH, Cortisol,
ACTH)
80061
(Alb, Ca, CO2, Cl, Creat, Glu, Phos, K, Na, BUN)
 Hepatic Function
(Alb, D-Bil, T-Bil, ALP, TP, ALT, AST)
 Hormone (Female)
(LH, FSH, Estradiol)
80076
PANEL
*LIMITED COVERAGE TEST, MEDICAL NECESSITY ICD-9 OR ABN REQUIRED