Wellness Screen - Sheridan Memorial Hospital printable pdf download

WELLNESS SCREEN

Sheridan Memorial Hospital

Street  Sheridan, WY 82801  (307) 672-1000

1401 West 5

Dr. William Doughty  (307) 672-1035

Location _______________________________________________

Please complete this form

Last Name____________________________________________ First Name ______________________________________________

Sex (check one)

_____ Male

DOB ______/_____/______

SSN __________/__________/__________ Physician __________________________

_____ Female

(a copy will be faxed to your physician)

Mailing Address ______________________________________City __________________________State _______ Zip Code _________

Phone Number (

) _________-______________

Hours fasting ____________If you have not fasted for 12 hours your

results may not be accurate.

(In case of critical test results we must be able to contact you)

GENERAL TEST REQUISTION (Please check with desired profile)

______Complete Blood Count

$15.00

CPT Code 85027

_____ Wellness Panel (includes TSH and

$50.00

CPT Code(s) 82040, 83540, 83735, 84100, 84443,

direct LDL)

84550, 86141, 82977, 83615, 82465, 83718, 84478,

83721

_____ Wellness Panel with Hemoglobin A1C

$75.00

CPT Code(s) (above codes for Wellness and 83036)

[$50.00 + $25.00 (HA1C)]

_____ Diabetic Management Panel

$35.00

CPT Code(s) 83036, 82947

May have up to 4 times per year

(Glucose + HA1C)

_____ Cholesterol

$ 5.00

CPT Code 82465

_____ PSA

$30.00

CPT Code 84152

_____ Occult Blood

$ 5.00

CPT Code 82270

TOTAL AMOUNT DUE _______________

Please initial. By initialing I am acknowledging that I understand and agree to the following statements:

______ Two (2) copies of results will be mailed to you. Please provide a telephone number that you can be reached at in the event any of

your test results fall into the critical result range.

NOTE: Please fill out your return envelope with your address

Received by _____________________________________________________________

Consent and Release

I hereby request and grant permission to Memorial Hospital of Sheridan County to draw blood from me for purpose of performing a set of standardized

laboratory tests on that sample. I request and authorize Memorial Hospital of Sheridan County to obtain those laboratory results and forward them to me.

I understand that I am responsible for forwarding this information to my personal physician or other source of health care and that the Memorial Hospital of

Sheridan County is not practicing medicine, proposing diagnoses, or recommending medical treatment, but merely acting as a resource to provide me this

additional information. I understand that should I become ill, have any complications, or have any questions regarding my health, I should contact my usual

source of health care. I do not hold Memorial Hospital of Sheridan County responsible in this regard. In the event of an accidental needle puncture, I consent

to any routine blood testing deemed necessary for the safety of the phlebotomist.

Participant

Signature _____________________________________________________________

Date ______________________________

Legal Guardian

(If Under 18) ___________________________________________________________

Date ______________________________

3 copies (1) Laboratory Copy (White)

(2) Receipt for Billing Dept (Yellow)

(3) Patient receipt/copy (Pink)

Tax ID: 836000241

1000680 12/17/10