Document intake
Reads what a lab receives, drafts what the order needs.
A document arrives in whatever condition the sender chose. Identity and insurance are read in the same pass — no per-clinic template to set up first.
FAX 03/12 07:52 FROM: NORTHGATE CLINIC P.1/3
CP
Cardinal Path Laboratories1820 Diehl Rd · Naperville, IL · CLIA 14D2099431
LABORATORY REQUISITIONREQ 4471-B
PATIENT INFORMATION
Patient name (last, first, MI)Whitfield, Dana R
Date of birth11/4/71
SexMF
Address418 Larkspur Ave
Phone(206) 555-0148
BILLING INFORMATION
Private ins.MedicareSelf payPrimary insurance / payorCascade Mutual
Policy / member ID8842-QX-1130
Group #55218
ORDERING CLIENT
PracticeNorthgate Clinic
PhysicianN. Okafor MD
SPECIMEN
Collected3/12 7:40a
FastingYesNo
TESTS REQUESTED — CHECK ALL THAT APPLY
CHEMISTRYBasic Metabolic (80048)Comp. Metabolic (80053)Lipid Panel (80061)TSH w/ reflex (84443)HbA1c (83036)
HEMATOLOGYCBC w/ Diff (85025)CBC w/o Diff (85027)ESR (85652)ICD-10Z00.00 Routine examE11.9 Type 2 diabetes+ R53.8
Physician signatureN. OkaforDate3/12
2
DRIVER LICENSE
W-4419-8827WHITFIELD, DANA R.DOB 11/04/1971
Drafted order · REQ 4471-B
2 to check
1Patient
NameWHITFIELD, DANA R.
SexF
Date of birth11 / 04 / 1971
Contact and address418 LARKSPUR AVE · (206) 555-0148
2Identifiers
Patient ID / MRN44-812-097
National ID / passport / licenceDL W-4419-8827
3Order
Referring organisation and providerNORTHGATE CLINIC · N. OKAFOR, MD
Collected03 / 12 07:40
3Clinical
Tests and panels, as writtenCMP · TSH REFLEX · CBC W/ DIFF
ICD-10Z00.00 · R53.8
Ask on order entryFASTING — 12 H
PriorityROUTINE
4Insurance
PayerCASCADE MUTUAL HEALTH
PositionPRIMARY
Member / policy no.8842-QX-1130
Group / group no.NG-TEAM / 55218
PDF · JPG · PNG · TIFF · MULTI-PAGE
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