LabCorp Voucher Instructions
For Participant Use Only
Thank you for participating in the BrandSafway screening program. The screening will consist of a single
venipuncture blood draw for a lipid panel and blood glucose. Only select LabCorp facilities are also
equipped to measure your height, weight, blood pressure and waist circumference.
Important: You must select Employee Wellness with body measurement when searching for a location
as detailed in Step 1 below. This voucher must be used by December 31, 2020.
3 steps to complete your LabCorp screening:
Find a facility. Vouchers are redeemable only at select LabCorp facilities. You will not be allowed to have
the screening test without the voucher. Expect the screening to take approximately 15 - 20 minutes.
To locate the nearest facility and schedule an appointment: Visit www.labcorp.com/findalab. Enter your
address or zip and select “Employee Wellness with body measurement” from the service options to
search for the nearest locations. On the next page choose your preferred clinic and select “Make
Appointment.” Fill in your appointment details and on the billing page, select “I have already paid or
someone else is responsible.”
Complete voucher form. On the attached voucher (page 2), please verify that the auto populated
information on the voucher is accurate:
• First and Last Name, sex, date of birth, address, city, state, zip code and phone number.
• Fill in the collection time, fasting state [Yes OR No] and collection date
• Enter or verify your unique ID in the space labeled “Patient ID.” Please consult your HR department if
you’re unsure about your unique ID. All other information can be left blank.
View results. Within three weeks of your screening, visit your
https://www.wellconnectplus.com/?company=5WNKWK where you can track your results. If you have not
received your results within four weeks of your screening, please contact
Support@lescustomercare.zendesk.com.
For LabCorp Use Only
• If you have any questions about processing the voucher, please call the LabCorp Wellness Division at 866-827-8046.
• Fasting is not required by this client. Do not turn anyone away for not fasting. Please mark Fasting or Non-Fasting.
• If you are unable to locate the account number in your LCM, please contact your Supervisor for assistance.
• Only screen for tests indicated on the LabCorp voucher. DON’T ask the participant which tests they would like to
receive.
Send additional copy of report to:
☐ Fax
( )
☐ Cell Client Number/Physician’s Name Phone/Fax Number
☐ Mail
BRANDSAFWAY
Physician’s Address City, State, Zip
To find the nearest patient
service center, visit www. c/o LabCorp Employer Services
labcorp.com or call 888- LABCORP WELLNESS VERIFIED
LABCORP (888-522-2677) 7617 Arlington Road
Bethesda, MD 20814
844-251-6524
ENTER ONLY THE ACCOUNT BELOW***
***E
CHECK ONE: $&&2817180%(5 19257575 ORDER NUMBER:
310822
03[X] ACCOUNT BILL: Patient’s Legal Name(Last, First, MI) Sex Date of Birth Collection Time Fasting Collection Date Urine hrs/vol
MO DAY YR PM ☐ Yes MO DAY YR P
HERNANDEZ JESUS M 07 11 1970 hrs______vol______
AM ☐ No L
E
NPI UPN Physician’s ID # Patient’s SS # Patient’s ID # A
JHERNAN8052 S
E
Physician’s Name (Last, First) Physician/Authorized Signature P
Hospital Patient Status: ☐ In-Patient ☐ Out-Patient ☐ Non-Patient
X _______________________ R
I
ORDERING PHYSICIAN Patient’s Address Phone N
PATIENT
Diagnosis/Signs/Symptoms in ICD-CM format in effect at Date of Service
107 LAUREL ST 979 709 1872 T
1477523488 Highest Specificity Required City LAKE JACKSON State TX ZIP 77566
DR. DAVID ASHLEY PRIMARY BILLING PARTY SECONDARY BILLING PARTY Name of Policy Holder (if different from patient)
RESP. PARTY
Insurance Carrier * Insurance Carrier *
Address of Policy Holder APT #
ID # ID #
Group # Group # City State ZIP
Insurance Address Insurance Address I hereby authorize the release of medical information related to the service described herein and authorize payment directly to LabCorp.
I agree to assume responsibility for payment of charges for laboratory services that are not covered by my healthcare insurer.
Name of Insured Person Name of Insured Person X______________________________________________________________________ ____________________________
Patient’s Signature Date
Relationship to Patient Relationship to Patient
MEDICARE ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
Employer Name Employer Name
Refer to Determining Necessity of ABN Completion on reverse.
* If Medicaid State Physician’s Provider # Workers Comp
☐ Yes ☐ No
TRAVEL LOG ID
P
____________ _____________ ____________ L
PST HR# DATE LOG# E
A
101300 - BIOMETRICS
S
E
262204 - LP+GLU P
R
I
N
T
Effective blood draw dates: 7/2/2020 - 12/31/2020
ORIGINAL-LABORTARY / COPY-CLIENT
NOTE: WHEN ORDERING TESTS FOR WHICH MEDICARE OR MEDICAID REIMBURSEMENT WILL BE SOUGHT, PHYSICIANS SHOULD ONLY ORDER TESTS THAT ARE MEDICALLY NECESSARY FOR THE DIAGNOSISI OR TREATMENT OF THE PATIENT. LISTED ABOVE
ARE THE CUSTOMIZED PROFILES YOU HAVE SPECIFICALLY REQUESTEED FROM LABCORP. THE INIDVIDUAL COMPONENTS HAVE BEEN DISCLOSED TO YOU AND THEY MAY ALSO BE ORDERED INDIVIDUALLY IN THE SPACE ABOVE. COMPONENTS AND BILL
CODES FOR NON-CUSTOMIZED TEST PROFILES ARE LISTED ON REVERSE. COMPONENTS MAY BE BILLED SEPARATELY IN ACCORDANCE WITH CARRIER POLICIES.
