Request Results or Add-Ons - CompuNet Clinical Laboratories

Client Service Request Form

All requests will be addressed within 1 business day. Requesting for multiple patients? Please complete one form for EACH patient.

Patient Last Name*

Patient Middle Initial*

Patient First Name*

Patient Date of Birth*

Date of Collection*

Requester Name/Title*

Office Phone Number*

Date of Add-On Request*

Request Type*Patient Testing Add-OnPatient Result Fax

Diagnosis Code(s)*

Add-On Test Code(s)* - (CompuNet Test Code Required)

Ordering Provider*

Ordering Account #

Account # / Practice Name - (If different from original ordering provider)

Office Address - (If no CompuNet account #)

Provider Name - (If different from original ordering provider)

NPI # - (If different from original ordering provider)

If requesting patient HIV results, please contact us at 937-297-8260. This request will not be processed until we confirm a secure fax with you via phone call.

Office Fax #*

Test(s) Results Requesting to be Faxed*

Ordering Provider*

Ordering Account #*

Ordering Provider NPI #*

Account # / Practice Name - (If different from original ordering provider)

Office Address - (If no CompuNet account #)

Provider Name - (If different from original ordering provider)

NPI # - (If different from original ordering provider)

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