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Quest Diagnostics PSC-Hold University of Miami

PSC-Hold - University of Miami
Collection Date: Collection Time:

28786-24575892(M

Quest Diagnosticsm Account #: 28786 LAB REF # 24575892Q8U

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C l i e n t ) Ordering Site I n f o r m a t i o n : Physician I n f o r m a t i o n : Account Name: Professional Arts Center Neurology Suites 603/609 Ordering: Koch, Sebastian Address 1: 1150 NW 14th Street Suite 609 Degree: MD Address 2: NPI: 1831155779 UPIN: Not on file City, State Zip: Miami, Florida, 33136 Phone: 305-243-6732 Physician ID: Patient Information: Name: CASTELLANOS FiERRERA,MARLENE Gender: Female Date of Birth: 9/19/1951 Age: 62 Address: 1780 SW 6 ST APT 3, APT 3 City, State Zip: MIAMI, FL 33135 SSN: w - ) a - 9 0 7 5 Patient ID: 20015193 Phone: 305-854-4214 Alt Controllil: 245758920BU 20015193 Specimen Type Blood Expected 10/2/2013

Orders
Code 7197 Test LYMPHOCYTE SUBSET PANEL 1 Dx 334.3

Responsible Party / Guarantor Information Name: CASTELLANOS HERRERA,MARLENE Address: 1 7 8 0 SW 6 ST APT 3 APT 3 MIAMI, Florida 33135 Phone: 305-854-4214 Relation to Patient: S e l f Insurance Information Primary Insurance: Carrier Code: Company Name: Address: MEDICAID MEDIPASS C PO BOX 7072 Tallahassee, Florida 32314-7084 2440097021

Employer Name: ABN:

Worker's Comp: N Date of Injury:

Policy Number: Group Number: Primary Policy Holder / Insured: Name: CASTELLANOS HERRERA,MARLENE Address: 1780 SW 6 STARTS APT 3 MIAMI, Florida 33135 Relation to Patient: Self