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Form Requisition 1327 Miller Road, Suite F Laboratory Testing Services Greenville, SC 29607 +1-864-568-8940 (o) Test Requisition: Toxicology +1-864-568-8942 (f) LuxorScientific.org Confidential An Innovative Scientific Solutions Company Requesting Provider & Insurance Information Patient Information Ordering Physician Client # Client Name Patient Name Client Street Address Client Phone Date of birth 侊 Male 侊 Female Patient’s Insurance Provider For This Test* Policy/Group No. Patient Address *Attach demo and 侊 Self Pay 侊 W/C Date of Injury Patient City/State/Zip Code front/back of card 侊 W/C Case Number Patient Phone Number ICD-10 Treatment Codes (include primary diagnosis code in “Other”) Explanation ܆ F10.20 ܆ F19.20 ܆ Z51.81 ܆ Z79.891 ܆ Identifies absence of prescribed medication ܆ F11.20 ܆ G89.4 ܆ Z91.19 ܆ Z79.899 ܆ Identifies undisclosed substances ܆ Other ܆ Identifies substances that contribute to adverse drug events or drug-drug interactions ܆ Baseline Test ܆ Periodic Monitoring ܆ Provides objectivity to the treatment plan ܆ High Risk Patient ܆ Confirmation Required ܆ Reinforces therapeutic compliance in the patient ܆ Targeted Testing ܆ Illicit Detection ܆ Other ܆ Inadequate Detection ܆ Best Practice Medications (attach patient’s medication list) ܆ Adderalů ܆ Celexa ܆ Dronabinol ܆ Hydromorphone ܆ Marinol ܆ Oxymorphone ܆ Seroquel ܆ Vicodin ܆ Adipex ܆ Cheratussin ܆ Duloxetine ܆ Kadian ܆ Meperidine ܆ Paroxetine ܆ Sertraline ܆ Vyvanse ܆ Alprazolam ܆ Citalopram ܆ Duragesic ܆ Keppra ܆ Methadone ܆ Paxil ܆ Soma ܆ Wellbutrin ܆ Ambien ܆ Clonazepam ܆ Effexor ܆ Klonopin ܆ Methylphenidate ܆ Pentazocine ܆ Sonata ܆ Xanax ܆ Amitriptyline ܆ Codeine ܆ Elavil ܆ Lamictal ܆ Mirtazapine ܆ Percocet ܆ Suboxone ܆ Zaleplon ܆ Amphetamine ܆ Concerta ܆ Escitalopram ܆ Lamotrigine ܆ Morphine ܆ Phenobarbital ܆ Subutex ܆ Zoloft ܆ Ativan ܆ Cyclobenzaprine ܆ Eszopiclone ܆ Levetiracetam ܆ MS Contin ܆ Phentermine ܆ Tapentadol ܆ Zolpidem ܆ Avinza ܆ Cymbalta ܆ Fentanyl ܆ Lexapro ܆ Neurontin ܆ Pregabalin ܆ Temazepam ܆ Zyprexa ܆ Bunavail Film ܆ Demerol ܆ Fioricet ܆ Limbitrol ܆ Norco ܆ Pristiq ܆ Tramadol ܆ Other ܆ Buprenorphine ܆ Desvenlafaxine ܆ Flexeril ܆ Lisdexamfetamine ܆ Nortriptyline ܆ Prozac ܆ Trazodone ܆ Cannabinoid/CBD ܆ Bup&Naloxone ܆ Dexamphetamine ܆ Fluoxetine ܆ Lorazepam ܆ Nucynta ܆ Quetiapine ܆ Triazolam ܆ Bupropion ܆ Diazepam ܆ Flurazepam ܆ Lortab ܆ Opana ܆ Remeron ܆ Tylenol #3 ܆ Butalbital ܆ Dihydrocodeine ܆ Gabapentin ܆ Lunesta ܆ Oxazepam ܆ Restoril ܆ Ultram ܆ Butrans ܆ Dilaudid ܆ Gralise ܆ Lyrica ܆ Oxycodone ܆ Ritalin ܆ Valium ܆ Carisoprodol ܆ Doxepin ܆ Hydrocodone ܆ Marijuana/THC ܆ OxyContin ܆ Roxicodone ܆ Venlafaxine Specimen Information Collector Name Specimen Type Date Collected Time Collected 4-Min Temp Ck Temp 90-100°F ܆ Urine ܆Oral Fluid ܆ Yes ܆ No ܆ Yes ܆ No Point-of-Care Screen Results Pos Neg Pos Neg Pos Neg Pos Neg ܆ ܆ Amphetamine ܆ ܆ Buprenorphine ܆ ܆ Methadone ܆ ܆ Oxycodone ܆ ܆ Barbiturates ܆ ܆ Cocaine ܆ ܆ Methamphetamine ܆ ܆ Phencyclidine (PCP) ܆ ܆ Benzodiazepines ܆ ܆ Marijuana (THC) ܆ ܆ Opiates ܆ ܆ Propoxyphene Toxicology Testing Request Custom Profiles Automatic Confirmations Immunoassay Screen (confirm if positive) ܆ Urine: ܆ Prescribed Medications (P029) ܆ Barbiturates (ϮϬϬ)* ܆ sĂůŝĚŝƚLJ;WϬϬϭͿΎ͗ƌĞĂƚŝŶŝŶĞΎ^'ΎƉ,Ύ ܆ Oral Fluid: ܆ Positive Point-of-Care Screens ܆ Ethanol (D217)* ܆ ŽŵƉƌĞŚĞŶƐŝǀĞ^ĐƌĞĞŶ;ϬϮϴͿΎ ܆ Ethanol Metabolites (D218)* ܆ ĂƐŝĐ^ĐƌĞĞŶ;yϬϬϵͿΎ Confirmation, Group Profiles ܆ Traditional Profile (P003) ܆ Comprehensive Profile (P004) ܆ Comprehensive Psych Prof (P006) ܆ Alkaloids (D021) ܆ Antiseizures (D020) ܆ Heroin (S033) ܆ Stimulants, Other (D002) ܆ Amphetamines (D001) ܆ Barbiturates (WϬϮϭ)* ܆ Illicits (D006) ܆ Synthetic Cannabinoids (D012) ܆ Anticonvulsants (D009) ܆ Benzodiazepines (D003) ܆ Methadone (S012) ܆ Synthetic Stimulants (D014)* ܆ Antidepressants, SNRI (D017) ܆ Buprenorphine (S084) ܆ Muscle Relaxants (D015) ܆ Synthetic Illicits (D011)* ܆ Antidepressants, SSRI (D016) ܆ Cocaine (S016) ܆ Opiates/Oxycodone (D004) ܆ THC (S082) ܆ Antidepressants, TCA (D019) ܆ Cough Suppressants (D008) ܆ Opiates Extended (D005) ܆ ĂŶŶĂďŝŶŽŝĚ;ͿWƌŽĨŝůĞƌĞĨůĞdž ܆ Antidepressants, Other (D018) ܆ Ethanol Metabolites (WϬϮϬ)* ܆ Sleep Aids (D010) ǁŝƚŚƉŽƐŝƚŝǀĞd,ĐŽŶĨŝƌŵĂƚŝŽŶͿΎ ܆ Fentanyl (S009) *Testing available for Urine Only Patient Informed Consent Requesting Provider Authorization I certify that the information provided on this form is true and accurate. I consent to the collection of a The provider certifies that the requested tests are medically necessary, that the medical necessity of requested specimen from myself or my minor child for the purpose of laboratory testing. My provider has discussed tests is documented in the patient’s chart, and the need for the requested tests has been explained to the laboratory options with me and I choose to have my testing performed by Luxor Scientific, LLC. I give Luxor patient. The provider also agrees to provide chart notes or other documentation within 72 hours when permission to release the results to the referring provider. In consideration of services rendered, I transfer requested by patients and/or insurers. The provider recognizes that the Centers for Medicare and Medicaid and assign my right to receive payment of authorized benefits of insurance to Luxor. I request that payment Services (CMS) and, increasingly, commercial insurers hold that toxicology confirmation testing is indicated of authorized benefits be made directly to Luxor on my behalf. I authorize Luxor to file appeals on my behalf when a toxicology screen is not consistent with the patient’s medical history, prescribed medications, clinical for any denial of payment and/or adverse benefit determination by my insurance company. I understand I presentation or the patient’s own statements. Toxicology confirmation testing may also be medically necessary am responsible for any co-pay, deductibles, non-authorized services and remaining balances after insurance when the provider determines toxicology screening will not provide the necessary breadth or quantification of reimbursement, or self-pay if uninsured. If my insurance carrier sends the payment directly to me for the results to meet the patient’s medical needs. service provided, I agree to endorse the insurance check and forward it to Luxor immediately. Signature Date Phone Number Signature Date T O X I C O L O G Y T E S T I N G P R O F I L E S Drug Class Urine Oral Fluid TRADITIONAL PROFILE Amphetamines, Benzodiazepines, Muscle Relaxants, Opiates/ Amphetamines, Benzodiazepines, Muscle Relaxants, Opiates/ Oxycodone, Extended Opioids, Other Stimulants, THC, and Oxycodone, Extended Opioids, Other Stimulants, THC, and Illicits Illicits COMPREHENSIVE PROFILE Includes TRADITIONAL PROFILE plus Anticonvulsants, Synthetic Includes TRADITIONAL PROFILE plus Anticonvulsants and Sleep Aids Stimulants, and Sleep Aids COMPREHENSIVE PSYCHO- Includes COMPREHENSIVE PROFILE plus Antiseizures and Includes COMPREHENSIVE PROFILE plus Antiseizures and THERAPEUTICS PROFILE Antidepressants (SNRI, SSRI, TCA, and Other) Antidepressants (SNRI, SSRI, TCA, and Other) Alkloids Cotinine, Mitragynine, 7-Hydroxymitragynine Cotinine, Mitragynine, 7-Hydroxymitragynine Amphetamines Amphetamine, Methamphetamine Amphetamine, Methamphetamine Anticonvulsants Gabapentin, Pregabalin Gabapentin, Pregabalin Antidepressants, SNRI Venlafaxine, Desvenlafaxine, Duloxetine Venlafaxine, Desvenlafaxine, Duloxetine Antidepressants, SSRI Citalopram, N-desmethylcitalopram, Escitalopram, Fluoxetine, Citalopram, N-desmethylcitalopram, Escitalopram, Fluoxetine, Norfluoxetine, Paroxetine, Sertraline Norfluoxetine, Paroxetine, Sertraline Antidepressants, TCA Amitriptyline, Desipramine, Doxepin, Imipramine, Nortriptyline Amitriptyline, Desipramine, Doxepin, Imipramine, Nortriptyline Antidepressants, Other Bupropion, Mirtazapine, Trazodone, Quetiapine, Risperidone, Bupropion, Mirtazapine, Trazodone, Quetiapine, Risperidone, Paliperidone (9-Hydroxyrisperidone) Paliperidone (9-Hydroxyrisperidone) Antiseizures Lamotrigine, Levetiracetam Lamotrigine, Levetiracetam Barbiturates Butalbital, Phenobarbital Benzodiazepines Alpha-hydroxyalprazolam, 7-Aminoclonazepam, Lorazepam, Alprazolam, Clonazepam, Lorazepam, Nordiazepam, Oxazepam, Nordiazepam, Oxazepam, Temazepam, Alpha- Temazepam, Diazepam, Chlordiazepoxide, Midazolam, hydroxymidazolam, Alpha-hydroxytriazolam Triazolam Buprenorphine Buprenorphine, Norbuprenorphine, Naloxone Buprenorphine, Naloxone Cough Suppressants Dextromethorphan Dextromethorphan Ethanol Metabolites Ethyl Glucuronide (EtG), Ethyl Sulfate (EtS) Illicits Benzoylecgonine (Cocaine Metabolite), 6-MAM (Heroin Metabolite), Cocaine, 6-MAM (Heroin Metabolite), Phencyclidine (PCP), MDMA Phencyclidine (PCP), MDMA (Ecstasy) (Ecstasy) Muscle Relaxants Carisoprodol, Meprobamate, Cyclobenzaprine Carisoprodol, Meprobamate, Cyclobenzaprine Opiates/Oxycodone Codeine, Morphine, Hydrocodone, Hydromorphone, Norhydrocodone, Codeine, Morphine, Hydrocodone, Hydromorphone, Oxycodone, Oxycodone, Oxymorphone, Noroxycodone Oxymorphone Opioids, Extended Includes Opiates/Oxycodone profile plus 6-MAM (Heroin Metabolite), Includes Opiates/Oxycodone profile plus 6-MAM (Heroin Me- Buprenorphine, Norbuprenorphine, Naloxone, Fentanyl, Norfentanyl, tabolite), Buprenorphine, Naloxone, Fentanyl, Methadone, Methadone, EDDP, Meperidine, Normeperidine, Tramadol, O- Meperidine, Tramadol, Pentazocine, Propoxyphene, Tapentadol, Desmethyltramadol, Pentazocine, Propoxyphene, Tapentadol, Naltrexone Naltrexone, 6-Betanaltrexol Sleep Aids Zaleplon, Zolpidem Zaleplon, Zolpidem Stimulants, Other Methylphenidate, Phentermine Methylphenidate, Phentermine Synthetic Cannabinoids AMM2201, JWH-018, JWH-073, JWH-210, JWH- 250, JWH-073 metabolite, AB-FUBINACA AB-FUBINACA, AB- PINACA Synthetic Stimulants Methylenedioxypyrovalerone (MDPV), Alpha- PVP (Flakka) Synthetic Illicits 25B-NBOMe, 25C-NBOMe, 25I-NBOMe, Desomorphine THC 11-Nor-Δ-9-carboxytetrahydrocannabinol Δ-9-Tetrahydrocannabinol Cannabinoid (CBD) Prole Cannabidiol (CBD), THC metabolites, and other common cannabinoids (reex with positive THC conrmation) Validity Creatinine, pH, Specific Gravity.
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