CLIENT #D8100

Direct Access Lab Test Order

:

Accession Label Lab Use Only

DAY

OPTIONAL: CompuNet is

Name (Last, First, Middle)________________________________________________________________________________________________________

Yto reach you at the phone numbers you provide. It is your responsibility to contact your physician. TO BE TESTED, YOU MUST READ AND INITIAL EACH SECTION BELOW:

I am 18 years or older.

I understand that, because a physician has not ordered these tests, my health insurance (including Medicare and Medicaid) will not pay for these tests. I will not ask my health insurer, Medicare, Medicaid, or any other federal or state health care program to pay for these tests.

I understand that CompuNet Clinical Laboratories will not submit these tests for reimbursement or payment to my health insurer, Medicare, Medicaid, any federal or state health program, or third party payer.

I am solely responsible for promptly talking with a physician about my lab test results. I understand that only my physician can interpret my test results.

I release and will not hold CompuNet Clinical Laboratories, LLC and CompuNet DIRECT responsible if I do not promptly communicate the results of these tests to my physician.

AMPM

FASTINGNON-FASTING

Anemia Screen - F (74646 - 1 SST, 1 LAV)

Complete Health Profile with Glycohemoglobin A1c - F $125

Total Cholesterol (only) -F (74797 - 1 SST)

Cardiac (Heart) Health Screen - F

Diabetes Screen (Glucose only) - F (74644 - 1 SST)

Diabetes Management Panel - F (74643 - 1 SST, 1 LAV) $49

$45

Thyroid Screen (TSH) (74648 - 1 SST)

Prostate Screen (PSA) (74647 - 1 SST)

Vitamin D Screen (74914 - 1 SST) $60

Glycohemoglobin A1c $29(74988 - 1 LAV)

$40

Basic Health Profile - F (75241 - SST) $50

(74641 - 2 SST)

Women’s

(74642 - 2 SST)Men’s Women’s

(74916 - 2 SST, 1 LAV)

(74645 - 1 SST)

$45

$45

$20

$20

Complete Blood Count with Diff (CBC) (75378 - 1 LAV) $35

(75242 - 1 SST) $30

Serum Iron and TIBC - F (75245 - 1 SST)

$30

(75338 - 1 SST)

(75335 - 1 SST)

(75337 - 1 SST)

(75332 - 1 SST)

(75333 - 1 SST)

(75339 - 1 SST)

T-Spot TB Test (75336 - Sod Hep Dk grn top tube)

(75334 - 1 SST)

$42

$50

$52

$42

$42

$42

$75

$42

Complete Health Profile - F $99

(74915 - 2 SST, 1 LAV)Men’s HEART HEALTH

PROFILES - TEST PACKAGES

DIABETES

GENERAL SCREENING

IMMUNOLOGY & INFECTIOUS DISEASES

Test Results will be mailed to you. Please allow one week for delivery. Contact us at (937) 297-8260 if you do not receive your results within 10 days.

PSC Use Only: Place Stamp Here

PATIENT SIGNATURE______________________________________________________________________ DATE_______________________________

F=Fasting required: Eat or drink nothing but water for 8-12 hours before your blood test. DO NOT stop taking your prescription medications. If your doctor advised you to take your medication with food, consult with your doctor before fasting.

Biometric Profile & Glucose - F SELECT LOCATIONS ONLY (75795 1 SST)

(75796 - 1 SST, 1 LAV) SELECT LOCATIONS ONLY

$65

$70

WELLNESS

Biometric Profile & A1c - F

2/15 REV