Clinician Support: 1 (855) 843-7200 Fax: (650) 852-9594 www.theranos.com TESTS ORDERED FOR Last Name First Name Address City Fasting _____hrs Microsample State Patient’s Choice Middle Initial DOB MM/DD/YY Zip Phone Email (circle one) Valid until MM/DD/YY Traditional Phlebotomy Standing Order Non-Fasting Sex M F Cash Pay Frequency: _________ per week / month / year TESTS ORDERED BY Clinician Name NPI Address City Copy To Fax Email State Zip Phone Fax Clinician Signature Date MM/DD/YY X ICD-9 code(s) required for Medicare or insurance reimbursement. ICD-9 code(s): COMMON PANELS , THYROID Panel components listed on reverse BMP - Basic Metabolic Panel 80048 $5.82 CBC, no Diff 85027 CBC w/ Auto Diff 85025 , capped at $49.95 Price capped at $49.95 for any combination of tests in this section. T3, Free - Triiodothyronine, Free 84481 $11.65 $4.45 T3, Total - Triiodothyronine, Total 84480 $9.75 $5.35 T4, Free - Thyroxine, Free 84439 $6.20 85007 $2.37 T4, Total - Thyroxine, Total 84436 $4.72 Celiac Panel 83516 $31.72 Thyroglobulin Antibodies 86800 $10.93 CMP - Comprehensive Metabolic Panel 80053 $7.27 Thyroid Peroxidase Antibody (TPO) 86376 $10.00 Electrolytes Panel 80051 $4.82 Thyroid Stimulating Hormone (TSH) 84443 $11.55 Hepatic Function Panel 80076 $5.62 Thyroid Uptake 84479 $4.45 Hepatitis Panel, Acute 80074 $31.89 87522 $29.44 Lipid Panel 80061 $9.21 Obstetric Panel 80055 $30.07 multiple $39.50 Reflex to HIV-1/2 Antibody Differentiation multiple $15.40 80069 $5.97 Reflex to Manual Diff & Smear Review Reflex to HepC, RNA Quant Obstetric Panel with HIV Renal Function Panel REPRODUCTIVE HEALTH capped at $59.95 Price capped at $59.95 for any combination of tests in this section. Estradiol 82670 $19.21 Follicle Stimulating Hormone (FSH) 83001 $12.77 Luteinizing Hormone (LH) 83002 $12.73 Progesterone 84144 $14.34 DHEA-S 82627 $15.28 Prolactin 84146 $13.32 Testosterone, Free 84402 $17.50 Testosterone, Total 84403 $17.75 STI capped at $59.95 Price capped at $59.95 for any combination of tests in this section. CHLAMYDIA/GONNORHEA + HIV W/ CONF multiple $44.95* Chlamydia/Gonorrhea, DNA Qualitative HIV 1/2 Antibody Screen Reflex to HIV-1/HIV-2 Ab Differentiation Hepatitis B Surface Antigen (HBsAg) Reflex to confirmatory Hepatitis C Antibody Screen URINE Microalbumin, Urine Microalbumin/Creatinine Urine Random ALPHABETICAL TESTS (H-Z) 86803 $9.81 87522 $29.44 Homocysteine 83090 $11.60 IgA, Serum 82784 $6.39 Insulin 83525 $7.86 Iron 83540 $4.45 Iron Binding Capacity, Total (TIBC) 83550 $6.01 Lead 83655 $8.32 Lipase 83690 $4.74 Magnesium 83735 $4.61 Hepatitis C Antibody Screen Reflex to Hep C RNA, Quant $3.98 Mumps Antibody IgG 86735 $8.97 multiple $7.53 Partial Thromboplastin Time (PTT) 85730 $4.13 $1.55 Phosphorus, Inorganic 84100 $3.26 84132 $3.16 Urinalysis, Auto 81003 Urinalysis, Complete 81001 $2.18 Potassium 87086 $5.55 Prothrombin Time (PT/INR) 85610 $2.70 PSA, Free 84154 $12.65 $12.65 Reflex to culture & susceptibility *Additional tests may be performed and charges incurred if urine culture tests positive STOOL PSA, Total 84153 Occult Blood Diagnostic, Fecal (1 card) 82272 $2.24 Rheumatoid Factor, Total 86431 $3.90 Occult Blood Screen, Fecal (3 cards) 82270 $2.24 Rubella Antibody, IgG 86317 $10.31 Rubeola Antibody, IgG 86765 $8.86 $4.10 Triglycerides 84478 $3.95 Thyroid Stimulating Hormone (TSH) 84443 $11.55 ALPHABETICAL TESTS (A-H) ABO/RhD Blood Typing multiple Alanine Aminotransferase (ALT) 84460 $3.64 Amylase 82150 $4.46 Reflex to T4 free 84439 $6.20 84550 $3.11 Antinuclear Antibodies, Screen (ANA) 86038 $8.31 Uric Acid Aspartate Aminotransferase (AST) 84450 $3.56 Varicella-Zoster Antibody 86787 $8.86 Calcium 82310 $3.55 Vitamin B-12 82607 $10.36 Cholesterol 82465 $2.99 Vitamin D 25-OH 82306 $20.35 Cortisol, Total 82533 $11.21 C-Reactive Protein (CRP) 86140 $3.56 C-Reactive Protein, High Sensitivity (hsCRP) 86141 $8.90 Creatine Kinase 82550 $4.48 Erythrocyte Sedimentation Rate (ESR/Sed Rate) 85652 $1.86 multiple $29.95 86703 $9.43 multiple $15.40 87340 $7.10 Ferritin 82728 $9.37 87341 $7.10 Folate 82746 $10.11 86803 $9.81 Gamma-Glutamyltransferase (GGT) 82977 $4.95 Glucose 82947 $2.70 Helicobacter Pylori, IgG, Serum 86677 $9.98 86695 $9.07 Herpes Simplex 2 (HSV2), IgG 86696 $13.30 Syphilis screen (Treponema pallidum IgG) 86780 $9.10 hCG - Pregnancy Screen, Blood Quantitative 84702 $10.35 86592 $2.94 Hemoglobin A1c (HbA1c) 83036 $6.67 Hepatitis B Surface Antibody (HBsAb) 86706 Visit www.theranos.com for complete test menu and pricing. , 82043 Herpes Simplex 1 (HSV1), IgG Reflex to RPR , Limited Medicare coverage based on diagnosis and frequency rules. OTHER TESTS/REQUESTED REFLEX TESTS/NOTES: $7.38 *Capped price offering. See reverse for details. Ordered reflex tests only performed when medically appropriate. For Medicare and Medicaid patients physicians should only order those tests that are medically necessary for diagnosis and treatment. GEN2.5 Panel Components Basic Metabolic Panel (BMP) CPT Code: 80048 Blood Urea Nitrogen (BUN) Calcium Total Chloride Carbon dioxide Creatinine Glucose Potassium Sodium CBC, No Diff CPT Code: 85027 Hematocrit Hemoglobin Platelets, Automated RBC, Automated WBC, Automated Celiac Panel CPT Code: 83516 x 4 Deamidated Gliadin Peptide (DGP) Ab, IgA Deamidated Gliadin Peptide (DGP) Ab, IgG Tissue Transglutaminase (tTG) Ab, IgA Tissue Transglutaminase (tTG) Ab, IgG Panel components may also be ordered individually based on your determination of medical necessity. Visit www.theranos.com for complete test menu and pricing. Chlamydia/Gonorrhea Panel, DNA Qual CPT Code: 87491/87591 Chlamydia Trachomatis, DNA, Qualitative N. Gonorrhea, DNA, Qualitative Comprehensive Metabolic Panel (CMP) CPT Code: 80053 Albumin Alkaline Phosphatase (ALP) Alanine Aminotransferase (ALT) Aspartate Aminotransferase (AST) Bilirubin Total Blood Urea Nitrogen (BUN) Calcium Total Chloride Carbon dioxide Creatinine Glucose Potassium Protein Total Sodium Electrolytes Panel CPT Code: 80051 Chloride Carbon dioxide Capped Price Offerings Chlamydia/Gonorrhea + HIV with Confirmation (Capped at $44.95) CPT Code: 87491/87592/86703/ 86701/86702 Chlamydia Trachomatis, DNA Qualitative N. Gonorrhea, DNA, Qualitative HIV-1/2 Antibody Screen Reflex HIV-1/HIV-2 Antibody Differentiation Reproductive Health (Capped at $59.95) CPT Code: 82627/82670/83001/ 83002/84146/84144/84402/84403 DHEA-S Estradiol FSH Potassium Sodium Hepatitis Panel, Acute CPT Code: 80074 Hepatitis A Antibody, IgM Hepatitis B Core Antibody, IgM Hepatitis B Surface Antigen (HBsAg) Reflex to HBsAg confirmatory Hepatitis C Antibody Screen Hepatic Function Panel CPT Code: 80076 Albumin Alkaline Phosphatase (ALP) Alanine Aminotransferase (ALT) Aspartate Aminotransferase (AST) Bilirubin Direct Bilirubin Total Protein Total Lipid Panel CPT Code: 80061 Cholesterol High-density Lipoprotein (HDL) Low-density Lipoprotein (LDL) Triglycerides Obstetric Panel w/ HIV Screen CPT Code: 80055/86703 ABO/RhD Ab Screen CBC w/ Auto Differential WBC Hepatitis B Surface Antigen (HBsAg) Reflex to HBsAg confirmatory HIV-1/2 Antibody Screen Reflex to HIV-1/HIV-2 Ab Differentiation Rubella Antibody, IgG Treponema Pallidum Antibody Reflex to RPR Renal Function Panel CPT Code: 80069 Albumin Calcium Total Chloride Carbon dioxide Creatinine Glucose Potassium Phosphorus, Inorganic Sodium The price for any combination of tests in each offering will not exceed capped price indicated. LH Prolactin Progesterone Testosterone Free Testosterone Total Reproductive Monitoring (Capped at $34.95) CPT Code: 82670/83001/83002/84144 Estradiol FSH LH Progesterone STI Comprehensive (Capped at $59.95) CPT Code: 87491/87591/57340/87341/ 86803/86703/86701/86702/86695/86696/ 86780/86592 Chlamydia, DNA, Qual Gonorrhea, DNA Qual HBsAg Reflex to HBsAg confirmatory HCV Antibody Screen HIV 1/2 Antibody Screen Reflex to HIV-1/HIV-2 Ab Differentiation HSV1 HSV2 Syphilis Screen (TP Ab) Reflex to RPR Thyroid (Capped at $49.95) CPT Code: 84481/84480/84439/84436/86800/ 84479/86376/84443 T3, Free T3, Total T4, Free T4, Total Thyroglobulin Antibodies Thyroid Uptake TPO TSH Support 1-855-843-7200 (option 2) For locations, visit www.theranos.com Lab services provided by Theranos, Inc., a CLIA-certified laboratory. Sample collection and related in-store services may be performed by Theranos-certified Walgreens personnel. Hours of operation are subject to change. Theranos is an independently owned and operated company, and is not an affiliate of Walgreen Co.
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