Agreement Form
On Demand 4 Kids & Adults Mobile Labs is responsible for the drawing and delivery of laboratory
specimens. OD4K&A does not collect any specimens without a physician order or a request from a
laboratory. OD4K&A is not allowed to give any medical advice, treat, or diagnose anyone.
OD4K&A needs patient information, copy of prescription and copy of insurance card (front and back)
48hours before scheduled appointment. If we do not receive the requested information in the time
range mentioned, then the scheduled appointment will be considered canceled. This is extremely
important so that we have adequate time to prepare for the blood draw and that we perform us
job correctly.
OD4K&A handles the delivery of all samples to their proper laboratory. If a sample is being collected
for a laboratory that needs to be picked up via courier service, OD4K&A is not responsible for any delay
of arrival to the laboratory, due to weather conditions or any other problems that may occur once
the sample has been delivered or picked up by courier service.
OD4K&A is not responsible for any errors that may occur at the laboratory. It is the labs responsibility
to process specimen once received by OD4K&A. In the event of a lab error, OD4K&A would gladly return
to recollect the sample at a discounted rate. Any error made by OD4K&A will be corrected at no extra
charge as long as all correct paperwork was submitted adequately prior to appointment.
Any billing questions or problems for tests collected for this service should be directed to your
insurance company or the laboratory billing department. Payment for services provided by OD4K&A
is collected on the day prior to appointment. MPS does not bill insurance companies, any claims
must be submitted by the client, with no guarantee of reimbursement.
Please be advised that Mobile Phlebotomy Services is not responsible for any outstanding
balances with LabCorp or Quest and will need to be settled prior to a scheduled home lab
draw. The labs have the right to decline specimens of patients with outstanding balances.
OD4K&A is an independent convenience service. Our company is not affiliated with any
laboratories or doctor’s offices. OD4K&A does not have the authorization to give discounts for any
lab tests that are being collected.
Under no circumstances will OD4K&A give out client's personal information to unauthorized
personnel. All client's information is always kept personal and confidential.
OD4K&A does not receive any results. In the event that your doctor did not receive results, it
is the responsibility of the Doctor office to get in touch with the lab. Most of the time they have
an account with the labs.
Please be considerate, in the event an appointment needs to be cancelled, MPS needs to be
given a 24-hour notice. We send confirmation out of courtesy, if you are a no show, you will be
charged an additional $25 to reschedule. We make it very easy for you to contact us with any
questions or concerns. We may not always be available by phone. You can also reach us via
email or text.
*For parents with children:
It is important to remember that this is a TEAM effort. If your child is getting their blood drawn
you must do your part. It is important to keep them hydrated 24 hours prior to scheduled blood
draw.
The less stress in the room the higher the success rate. We are almost always successful on the
first try, HOWEVER it may take up to 3 tries at times, this needs to be understood. This is normal,
especially with tiny veins and a moving target. We understand how stressful it can be for you and
your child during their blood draw, please understand how stressful it can be for us if we do not
have understanding parents.
Safety is very important. If you know that your child gets aggressive when upset, is difficult to
draw, or that it normally takes more than one person to hold them still it is extremely important
that you please let us know so that we can make arrangements to have a safe and successful draw.
I understand the above terms and conditions and agree to have my lab (and/or my son/daughter)
