Collection Date: * Phlebotomist's Initials an: dme of last dose: Phone am/pm Fasting:3g Set H's NO " IA s INSURANCE: Please attach a copy oF ROTH Skies et Patient's insurance card. Medicare Number: 0 SELF PAY: HDL Inc. will bill the patient. im Fr ASSIGNMENT OF BENEFITS Ai a mu:ten. Di I every reasonable e