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Cardiology Test Requisition Form Account #
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Document Date: 2014-05-22 10:42:59


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City

Insurance / Baltimore / /

Company

Insured Zip Self Group / CBS / MasterCard / American Express / CCI / /

Currency

USD / /

Event

FDA Phase / /

/

IndustryTerm

co-insurance and unmet deductible amounts / state law / search existing data resources / insurance billing / insurance / insurance billing questions / co-insurance and unmet deductible / insurance card / /

MedicalCondition

Hypertrophic Cardiomyopathy / Brugada Syndrome / Cardiomyopathy / Catecholaminergic Polymorphic Ventricular Tachycardia / genetic disease / Arrhythmogenic Right Ventricular Cardiomyopathy / disease / Code Physician/Genetic Counselor Epistaxis / genetic diseases / Alagille Syndrome / Noonan Syndrome / Short QT Syndrome / Address Heterotaxy City State Phone Fax Signature Email PAH/HHT Additional Reporting Address Congenital Heart Defect / Supravalvular Aortic Stenosis / Marfan Syndrome / Congenital Heart Disorder / disorder / specific genetic disease / Cardiac Amyloidosis / Holt-Oram Syndrome / genetic disorders / Long QT Syndrome / /

MedicalTreatment

blood transfusion / counseling / /

Organization

National Institute of Health / ELN / Medicare / /

/

Position

attorney / Code Physician/Genetic Counselor / Arrhythmia Ordering Physician Information Cardiomyopathy No Maximum QTc interval /

Product

R-131 / /

ProvinceOrState

Maryland / North Carolina / /

Technology

Diagnostic Tests / transplantation / human genome / /

URL

www.genedx.com/billing / www.genedx.com / /

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