Information Pr

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https://static.practicefusion.com/apps/ehr/index.html?#/PF/charts/patients/74acab5a-061e-46d0-a069-7075990c2b6c/orders/8727e13d-83e4-4eb1-83c… 1/1 ORDER #:

REQUESTING PROVIDER:

SENT:

Vendor Order

2006BC7R

2006BC7R

Joel Ramos

06/26/2020 03:47 pm

VENDOR NAME: Other -

NAME:

DOB:

GENDER:

ID:

PHONE:

ADDRESS:

PAYMENT PREFERENCE:

Patient information

Jose Nunez Narvaez

05/17/1981

M

J0636

787-***-****

Urb Rio Piedras Heights

1721 Calle Parana

San Juan, PR 00926

Patient - Cash

PRACTICE:

PROVIDER NAME:

NPI:

PHONE:

ADDRESS:

Requesting provider information

Joel Ramos Practice

Joel Ramos

145*******

787-***-****

Urb El Cerezal 1716 Parana

San Juan, PR 00926

NAME:

RELATION:

PHONE:

ADDRESS:

Responsible Party/Guarantor Information

Jose Nunez Narvaez

Self

787-***-****

Urb Rio Piedras Heights

San Juan, PR 00926

CODE TEST NAME STAT SPECIMEN DX

94504-8 SARS coronavirus 2 Ab.IgG & IgM panel No Z20.828, R05, R50.9 94531-1 SARS coronavirus 2 RNA panel No Z20.828, R05, R50.9 Electronically Signed By: Joel Ramos

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