Schedule Adherence Specialist Suggestion: 1. New/Initial Evaluation/Return Magnolia Medical Group | CLIA # 06D2121590 | NPI# 1043769862 after 2 months. th 2. Stabilizing/Weekly/Possible Laboratory Address: 10515 E 40 Ave, STE 115 Denver, CO 80239 th missed appts./Relapsed Office Address: 10515 E 40 Ave, STE 115 Denver, CO80239 3. Maintenance/Monthly/2x Phone: (303) 209-5115| Fax: (720) 638-5562| Email: [email protected] | Website: www.magnoliamed.com monthly/ No missed appts. Patient and Billing Information (Please use name printed on insurance card) Last Name First Name M.I. S.S.N. / Patient ID D.O.B. Street Address City State Zip Phone Gender Insurance Provider Policy # Group # Billing (Select One) Private Insurance Client Bill Write in ICD-10 Diagnosis Codes Medicare Medicaid Self-Pay Workers Comp Patient Release and Consent (Please attach copy of patient demographics and front and back of insurance card) Consent / Insurance Release: I voluntarily consent to the collection and testing of my specimen and certify that the specimen identified on this form is my own; it is fresh and has not been adulterated in any manner. I certify that the information provided on this form and on the specimen container is accurate. I authorize my insurance benefits to be paid directly to Magnolia Medical Group, for service I receive. I acknowledge that the lab may be an out-of-network facility within my insurance. I am also aware that in some circumstances my insurance will send the payment directly to me for the service provided. If this occurs, I agree to endorse the insurance check and forward it to the lab within 30 days of receipt. Failure to do so could result in my account being forwarded to collections. I agree to be financially responsible for these tests. I authorize the laboratory to release the results of this testing to the ordering facility. Patient Signature Date Urine Sample Screening and/or Confirmation Test Orders All Urine Samples Will Be Tested for Specimen Validity (Validity Includes: Creatinine, Oxidants, and pH) 3 4 Confirmation Testing by Generic Name, Metabolites Included if Available (LC-MS/MS) See Back for Full Metabolites List Mark to Order Confirmation Testing and if Prescribed to Patient ( are Illicit and/or Not Prescribed) Panels are bolded and may contain 1 or more drugs. If a panel is selected, all drugs listed below the panel name will also be tested. Temperature must be noted by the collector at collection time and written in the space provided. Alcohol Biomarkers Benzodiazepines Gabapentin Opioids and Opiate Analogs EtG Alprazolam Dextromethorphan EtS Aminoflunitrazepam Heroin Levorphanol Clonazepam 6-MAM Naloxone Amphetamines Diazepam Naltrexone Amphetamine Lorazepam Ketamine Methamphetamine Nordiazepam Oxycodone Oxazepam Methadone Oxycodone Antidep., Not Other. Spec. Temazepam Oxymorphone Bupropion Buprenorphine MDA Pregabalin Antidep., Serotonergic MDEA Citalopram Cannabinoids, Natural MDMA Sedative Hypnotics Fluoxetine THC-COOH Methylphenidate Zolpidem COOH Sertraline Mitragynine Cocaine Skeletal Muscle Relaxants Antidep., Tricyclic/Cyclical Benzoylecgonine Opiates Panel Carisoprodol Amitryiptyline Codeine Cyclobenzaprine Nortriptyline Fentanyls Dihydrocodeine Meprobamate Fentanyl Hydrocodone Barbiturates Sufentanil Hydromorphone Tramadol Butalbital Morphine Provider Order: 1. New/Initial Evaluation/Return after 2 months. 2. Stabilizing/Weekly/Possible missed appts./Relapsed. 3. Maintenance/Monthly/2x Monthly/No Missed Appts. Full Confirmation Testing 5 (Full Confirmation Includes All Confirmation Tests Listed Above Plus Metabolites Listed on Back) Provider Information Specimen Collection Information Additional Physician Requests / Notes: Date Collected Time Collected Temperature Provider Account Name (Print) Magnolia Medical Street Address City State Zip For Laboratory Use Only 1850 Race St Denver CO 80206 Received By Date Received Accession # Ordering Provider Name (Print) Ordering Provider Signature SOF Laboratory Requisition Form Urine Toxicology Front Revised: August 6, 2019 Magnolia Medical Group | CLIA # 06D2121590 | NPI# 1043769862 Laboratory Address: 10515 E 40th Ave, STE 115 Denver, CO 80239 Office Address: 10515 E 40th Ave, STE 115 Denver, CO80239 Phone: (303) 209-5115| Fax: (720) 638-5562| Email: [email protected] | Website: www.magnoliamed.com References from Front 1. Presumptive testing (screening by drug family) utilizes immunoassay and is a qualitative test that reports a positive or negative result (no numerical concentration). Confirmation by LC-MS/MS should be ordered separately ONLY if the healthcare provider deems it necessary to have information that presumptive testing alone will not provide (e.g. where the provider desires to test at levels below the cutoff for the presumptive test, when specific drug identification and numerical quantification is needed, or where cross-reactivity to other medications is a concern). Presumptive testing cannot be performed at the lab if Point-of-Care (POC) screening has already marked. 2. reening (IA). 3. Confirmation testing offers specific drug identification by a quantitative LC-MS/MS test and reports a numerical concentration result (e.g. nanograms per milliliter). If selected, there is no initial qualitative immunoassay test or second confirmatory test by an alternative method. This testing should be ordered separately ONLY if the healthcare provider deems it necessary to have information that initial presumptive immunoassay testing will not provide (e.g. where the healthcare provider desires to test at levels below the cutoff for the initial presumptive immunoassay tests, when specific drug identification and quantification may be necessary, or where cross- reactivity to other medications is a concern). 4. Confirmation Panel Test Listing with Metabolites Table: Metabolites are indented below their parent, indicates un-prescribed metabolites that are tested along with the parent analyte, indicates that Magnolia confirms the Metabolite only and not the parent analyte: Alcohol Biomarkers Benzodiazepines Cont. Heroin Opioids and Opiate Analogs EtG Aminoclonazepam 6-MAM Dextromethorphan EtS Diazepam Ketamine Levorphanol Amphetamines Nordiazepam Ketamine Naloxone Methamphetamine Temazepam Norketamine Naltrexone Amphetamine Oxazepam Methadone Oxycodone Antidepressants, Serotonergic Aminoflunitrazepam Methadone Oxycodone Citalopram Lorazepam EDDP Noroxycodone N-Desmethylcitalopram Buprenorphine Methylenedioxyamphetamines Oxymorphone Fluoxetine Buprenorphine MDA Noroxymorphone Sertraline Norbuprenorphine MDEA Pregabalin Antidepressants, Not Other Spec. Cannabinoids, Natural MDMA Pregabalin Bupropion THC-COOH Methylphenidate Sedative Hypnotics Antidepressants, Tricyclic/Cyclicals Cocaine Methylphenidate Zolpidem COOH Amitriptyline Benzoylecgonine Ritalinic Acid Skeletal Muscle Relaxants Nortriptyline Fentanyls Opiates Panel Carisoprodol Barbiturates Fentanyl Codeine Meprobamate Butalbital Norfentanyl Dihydrocodeine Cyclobenzaprine Benzodiazepines Sufentanil Morphine Tramadol Alprazolam Gabapentin Hydrocodone Tramadol Hydroxyalprazolam Gabapentin Norhydrocodone O-Desmethyltramadol Clonazepam Hydromorphone Mitragynine 5. tested. Laboratory Requisition Form Urine Toxicology Back Revised August 6, 2019.