Outpatient Referral Form - Childrens Hospital Los Angeles

ADVERTISEMENT

Children’s Hospital Los Angeles
California State License CLF260
Alexander R. Judkins, MD
CLIA# 05D0542989
Department of Pathology & Laboratory Medicine
Pathologist–in-Chief and Laboratory Director
4650 Sunset Boulevard
Los Angeles, CA 90027
Phone: 323.361.2423, 877.543.9522
Please help to avoid delays! Provide complete and legible information & a full copy of the insurance card.
Patient Name (Last, First, MI) __________________________________________________________________ Date of Birth _____/_____/_____Sex: Female
Male
Patient Social Security # _________________________ Patient Phone ______________________________ Parent’s Soc Sec # _______________________________
Parent’s / Guarantor’s Name __________________________________________________________________________ Parent’s / Guarantor’s DOB _____/_____/______
Patient Address (or insured / responsible party) _________________________________________________________________________________________________
City _________________________ State _________ Zip ____________ Signature ___________________________________________________________________
Diagnosis / ICD9 codes ______________________________________________________ Insurance Co _____________________________________________________
Address ______________________________________________________________________________________________________________________________
Authorization # __________________________ Group # _______________________________________ Member # ______________________________________
I authorize the release of any medical information necessary for my insurance carrier to process this claim. I understand I may be held responsible for any portion of the
claim that the insurance company does not pay. This statement does not apply to Medicare or Medicaid recipients. I authorize payment directly to Children’s Hospital LA
Physician’s Name ______________________________________________________________________________________NPI # _____________________________
Address ______________________ _________________________________________________________________________________________________________
Physician’s Signature ____________________________________ Date _____/_____/______ Phone __________________________ Fax __________________________
Hematology
Chemistry
Panels (see back)
1015
Hemoglobin
L
85018
0035
Albumin
R
82040
0034 Electrolytes
80051
1020
Hematocrit
L
85014
0036
Alkaline Phos
R
84075
0032 Chem 8 Basic Metabolic Panel
80048
0010
Hemogram+platelet
L
85027
0037
ALT (SGPT)
R
84460
0033 Chem 14 Comprehensive Panel 80053
0014
CBC with Diff
L
85025
0038
AST (SGOT)
R
84450
0028 Lipid Panel
80061
CBC with Manual Diff
L
8500
0048
Amylase
R
82150
0031 Hepatic Panel
80076
7
001
Sed Rate
L
8565
0039
Bilirubin Direct
R
82248
R503 IBD First Step
R
2
1
0013
Retic
L
85045
0059
Bilirubin, neonate
R
82250
R904 IBD Panel
R
1055
Sickle Screen
L
85660
0040
Bilirubin Total
R
82250
R557 TPMT Propredict Genetics L
1065
NBT (white cell function)
G
86384
0041
BUN
R
84520
R553 PRO-Predict Metabolites
L
Coagulation
3446
LH (Luteinizing hormone)
R
83002
Drug Monitor
0020
PT
LB
85610
0067
Calcium Total
R
82310
3360 Dilantin (Phenytoin)
R
80185
0022
PTT
LB
85730
0049
Cholesterol Total
R
82465
3355 Phenobarbital
R
80184
Urinalysis
0051
Cholesterol HDL
R
83718
3365 Tegretol (Carbamazepine) R
80156
0090
Urinalysis
81002
0063
C-Reactive Protein (CRP)
R
86140
3300 Theophylline
R
80198
0091
Urine Microscopic
81015
0044
Creatinine
R
82565
3370 Valporic Acid (Depakene)
R
80164
0097
Urinalysis with Microscopic
81000
3185
Ferritin
R
82728
Microbiology
Serology
3444
FSH
R
83001
9150 Blood Culture
87040
4175
ANA
R
86039
0045
Glucose
R
82947
9321 Throat Culture
87081
4070
ASO
R
86060
3170
Iron
R
83540
9261 Urine Culture
87086
3508
Beta HCG Quant Tumor
R
84702
3175
Iron/TIBC
R
83550
9350 Feces Culture
87045
4167
EBV
R
Call
3135
LDH
R
83615
****
Susceptibility Testing (specify)
87184
4220
Hep B Surface Ab
R
86706
3465
Lead
RB
83655
9630 O&P
87177
4215
Hep B Surface Ag
R
87340
0068
Magnesium
R
83735
0083 Pin Worm Prep
87172
3598
Hgb A1C
L
83036
0056
Phosphorus
R
84100
0081 Influenza A&B DAA
87299
4250
Hgb Electrophoresis
L
83020
0046
Potassium
R
84132
0080 RSV DAA by EIA
87400
4235
HIV-1 Antibody
R
86703
3440
T3 Total
R
84480
Molecular Micro
4025
IgA
R
82784
3425
T4
R
84436
8100 Bordetella pertussis PCR
87798
4015
IgG
R
82784
3435
TSH
R
84443
8010 CMV PCR
87496
4020
IgM
R
82784
0066
Total Protein
R
84155
8020 EBV PCR
87798
4085
IgE
R
82785
0057
Triglyceride
R
84478
8000 HSV PCR
87529
0075
Mono Spot
R
86308
0058
Uric Acid
R
84550
Other Tests (Please List)
0076
Pregnancy Test (HCG) Qual Urine 84703
3785
VMA (urine)
R
84585
3507
Pregnancy Beta HCG Quant R
84702
3795
HVA (urine)
R
83150
4285
RA (Rheumatoid Factor)
R
86431
3790
5-HIAA (urine)
R
83497
Source
Collected Date
Collected Time
Collector’s Name
Comment
Please help to avoid delays! Provide complete & legible information & a full copy of the insurance card. Thanks!

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go