Label Here HonorHealth

E-Req
Epic

HonorHealth E-Req - Epic Page 1 of 1

TM

Account #: Collection
Date:
Bill Type:
Req/Control Collection
#: Time:
Client / Ordering Site Information: Physician Information:
Account Name: Ordering: Vidal, Edward
Address 1: Degree: NP
Address 2: NPI: 1386123305
City, State Zip: UPIN:
Phone: Physician ID:

Patient Information:
Name: FRANCISCO,MELINDA R Date of Birth: 9/11/1978 (44 years)
Gender: Female Phone: 623-213-5858
SSN: xxx-xx-xxxx Address: 1530 E SAHUARO DR APT 202
Patient ID: 3043061 PHOENIX AZ 85020-6406

Responsible Party / Guarantor Information:

Name: FRANCISCO,MELINDA R
Address: 1530 E SAHUARO DR APT 202
City, State Zip: PHOENIX, AZ 85020-6406
Phone: 623-213-5858
Relation to Pt: Self
Employer Name:

ABN: Worker's Comp: N Date of Injury:

Insurance Information:
Primary Insurance: Secondary Insurance:
Ins Code: Not on file Ins Code:
Ins Co Name: MERCY CARE PLAN Ins Co Name:
Address 1: PO BOX 982975 Address 1:
Address 2: Address 2:
City, State Zip: EL PASO, TX 79998-2975 City, State Zip:
Policy Number: A15450238 Policy Number:
Group #: Group #:
Primary Policy Holder / Insured: Secondary Policy Holder / Insured:
Name: FRANCISCO,MELINDA R Name:
Address: 1530 E SAHUARO DR APT 202 Address:
PHOENIX, AZ 85020-6406
Pt Relation to Subscriber: Self Pt Relation to Subscriber:

Specimen Type: Specimen Source:

(7160) Type and Screen: Blood (7160) Type and Screen: Blood
Comments:

Order Code Tests Ordered (Total: 1) Count Interval Expires

7160 Type and Screen 1 Once 1/31/2024

Diagnosis Codes:

Bill Type: Ins Code: Not on file