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© 2001 Fairfax Medical Laboratories, Inc.

PATIENT INFORMATION 
Account Number: (Starred box in center of invoice, 6 digits)
Patient Name:


INFORMATION FROM YOUR INSURANCE CARD  
Insurance Company (If PHCS, please provide the carrier's name):
Claims Office Address:
Policy Member ID#:
Group Number:
Employer:
Name of Insured:
Patients Relationship To Insured: (ie. mother, son, self)