Direct Access Lab Test Order

Direct Access Lab Test Order
DAY
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.
CLIENT #D8100
Lab Use Only
Accession Label
AM
:
PM
FASTING
NON-FASTING
OPTIONAL:
CompuNet is
Name (Last, First, Middle)________________________________________________________________________________________________________
Y
to 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.
PATIENT SIGNATURE______________________________________________________________________ DATE_______________________________
IMMUNOLOGY & INFECTIOUS DISEASES
PROFILES - TEST PACKAGES
$50
Basic Health Profile - F (75241 - SST)
Complete Health Profile - F
Women’s
Men’s (74641 - 2 SST)
$99
(74642 - 2 SST)
Complete Health Profile with Glycohemoglobin A1c - F
Men’s (74915 - 2 SST, 1 LAV)
Women’s (74916 - 2 SST,
Total Cholesterol (only) -F
1 LAV)
$20
(74797 - 1 SST)
(75242 - 1 SST)
DIABETES
Diabetes Screen (Glucose only) - F
Diabetes Management Panel - F
Glycohemoglobin A1c
(74644 - 1 SST)
(74643 - 1 SST, 1 LAV)
$30
$20
$49
$29
(74988 - 1 LAV)
GENERAL SCREENING
$45
Anemia Screen - F
(74646 - 1 SST, 1 LAV)
Complete Blood Count with Diff (CBC) (75378 Prostate Screen (PSA) (74647 Thyroid Screen (TSH)
Vitamin D Screen
$45
(74648 - 1 SST)
$45
(74914 - 1 SST)
$50
$52
T-Spot TB Test
(75332 - 1 SST)
$42
(75333 - 1 SST)
$42
(75339 - 1 SST)
$42
$75
(75336 - Sod Hep Dk grn top tube)
$42
(75334 - 1 SST)
WELLNESS
Biometric Profile & Glucose - F
Biometric Profile & A1c - F
(75795 1 SST) SELECT LOCATIONS ONLY
(75796 - 1 SST, 1 LAV) SELECT LOCATIONS ONLY
$65
$70
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.
$35
1 SST)
Serum Iron and TIBC - F
(75245 - 1 SST)
1 LAV)
(75335 - 1 SST)
(75337 - 1 SST)
$40
(74645 - 1 SST)
$42
$125
HEART HEALTH
Cardiac (Heart) Health Screen - F
(75338 - 1 SST)
PSC Use Only:
Place Stamp Here
$60
$30
2/15 REV