1. The Person filling the Order Company Name if applicable Person filling the order * First Name Last Name Phone for Billing Questions * (###) ### #### Email for Invoice * 2. Patients's Information Patients Full Name * First Name Last Name Patient's Date of Birth * MM DD YYYY Patient's Gender * Male Female 3. Service Details Service Requested * Blood Draw and Specimen Delivery Blood Specimen Delivery Other Specimens Required Checkbox Comprehensive Metabolic Panel (14)(CMP) (CPT CODE:80053) Complete Blood Count (CBC) with Differential (CPT CODE:85025) International Normalized Ratio (INR) (CPT CODE:85610) Lipid Panel (CPT CODE:80061) Prothrombin Time (PT) (CPT CODE:85610) Hemoglobin (Hb) A1c (CPT CODE:83036) Vitamin D, 25 Hydroxy (CPT: CODE:82306) Metabolic Panel (8) Basic (CPT CODE: 80048) Other Is fasting required? * Yes No Number of Specimens * e.g 1 CBC and 1 CMP is 2 Specimens enter 2 Refrigeration Handling required? * Yes No Name of the Lab to process the blood specimen * example LabCorp e.t.c Address for the Lab to process the Blood Specimen. * Address 1 Address 2 City State/Province Zip/Postal Code Country Time of Delivery * Stat/Priority Same Day Next Day 4. Services Details Frequency if Needed ? e.g every Wednesday, 08/26/2019 - 09/30/2019 Service Visit Date * MM DD YYYY Service Location (Home, Office, Facility) * Patient's Phone Number * (###) ### #### Service Address * Address 1 Address 2 City State/Province Zip/Postal Code Country 5. Compliance & Documentation DOCTOR INFORMATION Providers Name Providers Address Address 1 Address 2 City State/Province Zip/Postal Code Country Providers Phone (###) ### #### Fax (###) ### #### Has the provider's order been uploaded/attached? Yes No Does this include Protected Health Information (PHI) Yes No 6. Authorization I Authorize Mona Health Services to provide onsite phlebotomy services as desscribed above Signature First Name Last Name Today's Date * MM DD YYYY 7. Payment & Billing Payment Method * Insurance Self-Pay (Invoice) – Receive an invoice to pay later (out-of-pocket). Online Payment Account Number Cash at Visit Our standard Service area includes Mount Juliet, Hermitage, Old Hickory, Donelson, western Lebanon, and nearby East Nashville — within 15 miles of ZIP 37122. Travel beyond this area may include a mileage fee.” Miles from Service Base (37122) — Number field to let clients enter mileage. Travel Zone 0–10 miles (no travel charge) 11–20 miles (+$10) 21–30 miles (+$20) 31–40 miles (+$30) Over 40 miles (enter exact miles, $1/mile) Invoice Delivery * Email Mail FAX Third-Party Billing Contact Optional Fields Purchase Order # / Reference Code If your organization requires a PO# or reference for billing, enter it here. Leave blank if N/A Notes for Billing Department Enter any special instructions (e.g., use patient chart #, send copies to another email) Thank you! An Invoice will be emailed to you shortly. Service Area
