PHLEBOTOMY SERVICE AGREEMENT FORM

THE COMPANY: DOMINION ANESTHESIA, PC DOING BUSINESS AS DOMINION HEALTH CARE

PATIENT SERVICE CENTER. (DHCPSC) of 1220 Walter Reed Road Fayetteville, North Carolina 28304

  • The Company will perform daily routine lab draws at _______________________________facility located at ____________________ and _____________________address for a fee of $4900.
  • The Company will be available to perform urgent, emergent or stat lab draw for an additional fee of $20, $25, $30 respectively.
  • The drawing and processing of laboratory specimens is the responsibility of the Company. 
  • Without a physician’s order or a laboratory request, the Company does not collect any specimens. 
  • The Company is not permitted to provide medical advice, treatment, or diagnosis. 
  • All samples are delivered to the appropriate laboratory by the Company. _____________hours prior to booked appointment, patient information, copy of prescription, and copy of insurance card (front and back) are required. If the needed information is not received within the specified time frame, the planned appointment will be canceled. This is critical in order for us to have enough time to prepare for the blood draw and to do our work appropriately.
  •  A client will not be provided a sample to handle under any circumstances. 
  • If a sample is being collected for a laboratory and must be picked up by courier service, The Company is not liable for any delays in delivery to the laboratory caused by weather or any other problems that may arise after the sample has been delivered or picked up by courier service. 
  • The Company is not liable for any mistakes made in the laboratory. The Company would gladly return to collect the sample at a discounted rate if there was a lab error. 
  • The Company will rectify any errors it has made at no additional cost subject to proper submission of all correct paperwork before appointment.
  • Any billing inquiries or issues relating to this service’s testing should be directed to your insurance company or the laboratory’s billing department. 
  • Invoice payments should be made to the Company biweekly or weekly.
  • Certain services are billed to insurance companies by the Company; however, any claims must be submitted by the client, with no guarantee of reimbursement.
  • The Company is a mobile phlebotomy service that is independent.  There are no affiliations between the Company and any laboratory or doctor’s offices. 
  • The Company is not authorized to provide discounts for any lab tests that are gathered. 
  • The Company will never give out a client’s personal information to unauthorized people. All client information is kept private and confidential at all times. 
  • No findings are received by the company. If your doctor has not received results, it is the obligation of the doctor’s office to contact the laboratory.
  • If you cancel an appointment without giving the Company a ___________hour (s) notice, you will be charged an extra $ to reschedule.

I agree to the aforementioned terms and conditions and give permission for my lab sample to be taken.

Signature_____________________ Date_________________ 

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