theranos support: +1 855 843-7200 fax: +1 650 852-9594 theranos.com TESTS ORDERED FOR Last Name
First Name
Middle Initial
DOB MM/DD/YY
Sex M
Address
City
Fasting _____ hrs
Microsample
State
Patient’s Choice
Zip
Traditional Phlebotomy
Phone
Standing Order
Non-Fasting
F
(circle one)
Valid until MM/DD/YY
Frequency: __________ per week / month / year
Cash Pay
REQUIRED ICD-9/ICD-10 code(s):
TESTS ORDERED BY Clinician Name
NPI
Address
City
State
Zip
Phone
Copy To
Fax
Clinician Signature
Fax
Date MM/DD/YY
x COMMON PANELS All tests available on an individual basis. Panel components listed on reverse.
BMP – Basic Metabolic Panel 80048 CBC, no Diff 85027 CBC w/ Auto Diff 85025 CMP – Comprehensive Metabolic Panel 80053 Electrolytes Panel 80051 Epstein Barr (EBV) Antibody Panel multiple Hepatic Function Panel 80076 Hepatitis Panel, Acute with confirmation 80074 Reflex to HBsAg confirmation 87341 Reflex to HepC, RNA Quant 87522 Lipid Panel 80061 Obstetric Panel with HIV screen and confirmation multiple Reflex to HBsAg confirmation 87341 Reflex to HIV-1/HIV-2 Ab Diff multiple Reflex to HIV-1 RNA Quant 87536 Reflex to RPR multiple Reflex to TP-PA multiple Renal Function Panel 80069
$5.76 $4.41 $5.29 $7.19 $4.78 $35.11 $5.56 $31.58 $7.03 $29.15 $9.11 $46.46 $7.03 $15.25 $57.90 $2.91 $9.01 $5.91
REPRODUCTIVE HEALTH
84481 $11.53
T3, Free – Triiodothyronine, Free T3, Reverse – Triiodothyronine, Reverse T3, Total – Triiodothyronine, Total T4, Free – Thyroxine, Free T4, Total – Thyroxine, Total Thyroglobulin Antibodies Thyroid Peroxidase Antibody (TPO) Thyroid Stimulating Hormone (TSH) Reflex to T4 free Thyroid Uptake
84482 $10.73 84480
$9.65
84439
$6.14
84436
$4.68
86800 $10.83 86376
$9.90
84443 $11.44 84439
$6.14
84479
$4.41
82043
$3.94
multiple
$7.46
81003
$1.53
81001
$2.16
87086
$5.50
URINE
Microalbumin, Urine Microalbumin/Creatinine Urine Random Urinalysis, Auto Urinalysis, Complete Reflex to culture & susceptibility
Additional tests may be performed and charges incurred if urine culture tests positive.
Iron Iron Binding Capacity, Total (TIBC) Lactate Dehydrogenase Lipase Magnesium Parathyroid Hormone (PTH) Partial Thromboplastin Time (PTT) Phosphorus, Inorganic Prothrombin Time (PT/INR) PSA, Free PSA, Total Rheumatoid Factor, Total Uric Acid Varicella-Zoster Antibody Vitamin B-12 Vitamin D 25-OH
83540
$4.41
83550
$5.95
83615
$4.11
83690
$4.69
83735
$4.56
83970 $28.09
85730
$4.09
84100
$3.23
85610
$2.68
84154 $12.52 84153 $12.52 86431
$3.86
84550
$3.08
86787
$8.77
82607 $10.26 82306 $20.15
OTHER TESTS/REQUESTED REFLEX TESTS/NOTES:
ALPHABETICAL TESTS (A–I)
DHEA-S Estradiol Follicle Stimulating Hormone (FSH) hCG – (Maternal), Blood Quantitative Luteinizing Hormone (LH) Progesterone Prolactin Sex Hormone Binding Globulin (SHBG) Testosterone, Free Testosterone, Total
82627 $15.13
Chlamydia Trachomatis, DNA Qualitative Hepatitis B Surface Antigen (HBsAg) Reflex to HBsAg confirmation Herpes Simplex 1 (HSV1), IgG Herpes Simplex 2 (HSV2), IgG HIV screen with confirmation Reflex to HIV-1/HIV-2 Ab Diff Reflex to HIV-1 RNA Quant N. Gonorrhea, DNA Qualitative Syphilis screen with confirmation Reflex to RPR Reflex to TP-PA
87491 $12.06
82670 $19.01 83001 $12.65 84702 $10.25 83002 $12.60 84144 $14.20 84146 $13.19 84270 $14.79 84402 $17.33 84403 $17.57
STI
ALPHABETICAL TESTS (I–Z)
THYROID
87340
$7.03
87341
$7.03
86695
$8.98
86696 $13.17 87389 $16.39 multiple $15.25 87536 $57.90 87591 $12.06 86780
$9.01
86592
$2.91
86780
$9.01
ABO/RhD Blood Typing multiple $4.06 Amylase 82150 $4.41 Antinuclear Antibodies, Screen (ANA) 86038 $8.23 Reflex to ANA confirmation 86039 $7.60 Cortisol, Total 82533 $11.10 C-Reactive Protein (CRP) 86140 $3.52 C-Reactive Protein, High Sensitivity (hsCRP) 86141 $8.81 Creatine Kinase 82550 $4.43 Erythrocyte Sedimentation Rate (ESR/Sed Rate) 85652 $1.84 Ferritin 82728 $9.27 Folate 82746 $10.01 Gamma-Glutamyltransferase (GGT) 82977 $4.90 Glucose 82947 $2.67 Glucose Tolerance Test (GTT), 3hr, 100g multiple $11.43 Helicobacter Pylori, IgG 86677 $9.87 Hemoglobin A1c (HbA1c) 83036 $6.61 Hepatitis B Surface Antibody (HBsAb) 86706 $7.31 Hepatitis C Antibody Screen 86803 $9.71 Reflex to HepC, RNA Quant 87522 $29.15 Homocysteine 83090 $11.48 IgA 82784 $6.33 Insulin 83525 $7.78
Visit theranos.com for complete test menu and pricing. Limited Medicare coverage based on diagnosis and frequency rules. Ordered reflex tests only performed when medically appropriate. For any payer with a medical necessity requirement (including Medicare and Medicaid), physicians should only order those tests that are medically necessary for diagnosis and treatment.
Sample Collection Date/Time GEN2.8
panel components
All tests available on an individual basis. A complete list of tests, descriptions, and prices can be found at theranos.com or on the Theranos app.
Basic Metabolic Panel (BMP)
Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride • Creatinine • Glucose • Potassium • Sodium
Complete Blood Count (CBC)
Hematocrit • Hemoglobin • Platelets, Automated • RBC, Automated • WBC, Automated
Comprehensive Metabolic Panel (CMP)
Alanine Aminotransferase (ALT) • Albumin • Alkaline Phosphatase (ALP) • Aspartate Aminotransferase (AST) • Bilirubin Total • Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride • Creatinine • Glucose • Potassium • Protein Total • Sodium
Electrolytes Panel
Carbon dioxide • Chloride • Potassium • Sodium
Epstein-Barr (EBV) Antibody Panel
EBV Nuclear Ab IgG • EBV Viral Capsid Antigen (VCA)-IgG • EBV Viral Capsid Antigen (VCA)-IgM
Hepatic Function Panel
Alanine Aminotransferase (ALT) • Albumin • Alkaline Phosphatase (ALP) • Aspartate Aminotransferase (AST) • Bilirubin Direct • Bilirubin Total • Protein Total
Hepatitis Panel, Acute
Hepatitis A Antibody, IgM • Hepatitis B Core Antibody (HBcAb), IgM • Hepatitis B Surface Antigen (HBsAg) with reflex to HBsAg confirmation (+$7.03)* • Hepatitis C Antibody Screen
Lipid Panel
Cholesterol • High-density Lipoprotein (HDL) • Low-density Lipoprotein (LDL) • Triglycerides
Obstetric Panel with HIV screen
ABO/Rhd Blood Type, Antibody Detection, RBC, CBC with Auto Diff, WBC • Hepatitis B Surface Antigen (HBsAg) with reflex to HBsAg confirmatory (+$7.03)* • HIV screen - HIV-1/HIV-2 Ag/Ab Combo with reflex to confirmation (HIV-1/HIV-2 Ab Diff (+$15.25) with reflex to HIV-1 RNA Quant (+$57.90))* • Rubella Antibody, IgG • Syphilis screen with reflex to confirmation (Treponema Pallidum IgG with reflex to RPR (+$2.91)* with reflex to TP-PA (+$9.01)*
Renal Function Panel
Albumin • Blood Urea Nitrogen (BUN) • Calcium Total • Carbon dioxide • Chloride • Creatinine • Glucose • Phosphorus, Inorganic • Potassium • Sodium
= Fasting recommended. *Ordered reflex tests only performed when medically necessary. Lab services provided by Theranos, Inc., a CLIA-certified laboratory. Theranos is an independently owned and operated company.