Free Statement - District Court of Arizona - Arizona


File Size: 106.7 kB
Pages: 4
Date: December 31, 1969
File Format: PDF
State: Arizona
Category: District Court of Arizona
Author: unknown
Word Count: 585 Words, 4,082 Characters
Page Size: 620.64 x 792.24 pts
URL

https://www.findforms.com/pdf_files/azd/34801/83-14.pdf

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EXHIBIT 12
Case 2:03-cv-01729-RCB Document 83-14 FiIed10/31/2005 Page10f4

. »AR1z0:~1A DEPARTMENT OF CORRECTIONS T ·*TT·**~EH?*IE—NT E
E CONSULTATION REQUEST A · · I
NEW DENIAL A;¤p5AI_[ ] SPECIALTY! CODE ANTICIPATED
· M PRIOR CONSULT# I {I , , if RELEASE D**~TE&OS/E
. DN SITE[ I OFF SITEM TELEMEDICINE YES [ ] ( NOM _ I _
I ` ‘ . IF M0. REAS©N · i
REASONFOR REFERRAL {{,,7/ Q · I- · _ »
__ PROBLEM LIST (CI-IRONIC/ACUTE) ‘ E ' I '· I
._ , { Q » U _ ‘ -
MEDICAL ALLERGIES: 9, ' U . A · _
CURRENT MEDICATIONS: V . I E ‘ _
_ COMPLIANCE ISSUES NO[ }YES[ ] Explain: 1 _ · · _ _
SNO»s ° ‘ - LAB I RESULTS
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EXHIBIT 13
Case 2:03-cv-01729-RCB Document 83-14 FiIed10/31/2005 Page30f4

Laboratory Corporation of America 1
SPECIMEN TYPE PRIMARY LAB REPORT STATUS)
303—237—6179-0 S S PD COMPLETE Page #: 1 .
i ADDITIONAL INFORMATION Q . ______' ___
` 1 CLINICAL INFORMATION
` FASTING: N CD- 84025069465 ~
FR—SR DOB: 2/25/1963 g —————~— —-»»————£
1 PHYSICIAN ID. g PATIENT ID.
9 PATIENT NAME 1 SEX 1 AGE(YR./MOS.) _ Q MACABUHAYR 10200] i
g M 39 1 8 1
, ACCOUNT. ASPC-I_EWIS
{ PT. ADD.: `
26700 S. HWY 85 ;
DATE OFSPECIMEN TIME DATE RECEIVED1 DATE REPORTED TIME BUCKEYE AZ 85326_O0O0 1
10/30/2002 0;00 10/31/2002 11/06/2002 8¤23 E 599I )ACCOUNT NUMBER: 02256542

Q TEST RESULT IJNHTS LAB E
`
HCV QUANTASURE PLUS (SERIAL) `
International Units TG
3,200,000 IU/mL
Note: TG
This test measures HCV RNA using real-time Polymerase *_
Chain Reaction (PCR) technology. The assay was developed “
and its performance characteristics were determined by
LabCorp. It has not been cleared or approved by the U.S.
Food and Drug Administration.
The FDA has determined that such clearance or approval
is not necessary. This test is used for clinical
purposes. It should not be regarded as investigational
or for research.
LAB: TG LABCORP RTP DIRECTOR: MYLA LAI-GOLDMAN MD
1912 ALEXANDER DRIVE, RTP, NC 27709—OOOO
I A /1/ 7 Z 0 V
` A RDNOLFO MACABUHAIC MD
DEA BA6086020-105
g Results are Elagged in Accordance with Age Dependent Reference Ranges
Last Page of Report
L _ ‘ 4 f 4 »·
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