HOW TO ORDER YOUR OWN LAB TESTS FROM COMPUNET

HOW TO ORDER YOUR OWN LAB TESTS FROM COMPUNET

Thank you for your interest in CompuNet Clinical Laboratories Direct Access Lab Testing. Here are four easy steps to order your own lab testing.

1. Access the order form at:

2. Print your order form, complete all information and take your order to any CompuNet Patient Service Center. We have centers throughout the Dayton/Springfield, Ohio region. No appointment is needed. For a full list of locations go to:

3. Payment will be collected at the time of service. We accept checks and credit cards. We are unable to accept cash or money orders.

4. To get online access to your lab results, sign-up for a My Labs Now account by texting MYLABS to 66349 from your smartphone, or sign-up at

For more information about the direct access tests we offer visit:

Direct Access Lab Test Order

DAY

CLIENT #D8100

F=Fasting recommended: 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 your doctor before fasting.

Lab Use Only

AM

FASTING

:

PM

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.

PROFILES - TEST PACKAGES

Basic Health Pr - F (75241 - SST)

Complete Health Pr - F

Men's (74641 - 2 SST)

Women's (74642 - 2 SST)

Complete Health Pr e with Glycohemoglobin A1c - F

Men's (74915 - 2 SST, 1 LAV)

Women's (74916 - 2 SST, 1 LAV)

HEART HEALTH

Cardiac (Heart) Health Screen - F (74645 - 1 SST)

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

(75242 - 1 SST)

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

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

Glycohemoglobin A1c (74988 - 1 LAV)

GENERAL SCREENING Anemia Screen - F

(74646 - 1 SST, 1 LAV)

Complete Blood Coun

Prostate Screen (PSA) (74647 - 1 SST)

(75378 - 1 LAV)

Thyroid Screen (TSH) (74648 - 1 SST)

Vitamin D Screen (74914 - 1 SST)

Serum Iron and TIBC - F

(75245 - 1 SST)

$50 $99

$125

$40 $20 $30

$20 $49 $29

$45 $35 $45 $45 $60 $30

IMMUNOLOGY & INFECTIOUS DISEASES

(75338 - 1 SST) (75335 - 1 SST)

(75337 - 1 SST) (75332 - 1 SST)

$42 $50 $52 $42

(75333 - 1 SST)

$42

(75339 - 1 SST)

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

$42 $75

WELLNESS

(75334 - 1 SST)

$42

F (75795 1 SST) SELECT LOCATIONS ONLY $65 F (75796 - 1 SST, 1 LAV) SELECT LOCATIONS ONLY $70

Mailed Results may take up to 2 weeks for delivery. Results through My Labs Now are available as soon as results are released from lab. Contact us at (937) 297-8260 if you do not receive your results within 2 weeks.

PSC Use Only: Place Stamp

6/18

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