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A. CLINIC INFORMATION Clinic Name/Account # Clinic Street Address

City, State, Zip Code Toxicology Requisition rev20190327 B. SAMPLE INFORMATION * All fields REQUIRED for processing * Requesting Provider Date & Time Collected Collector Initials Specimen Type AM □ Urine □ Oral Fluid / / : PM * Enter Panel Code in Section E *

C. PATIENT INFORMATION * All fields REQUIRED for processing * □ Check if supporting documents attached (copy of front/back of insurance card(s) and Driver's License) Last Name First Name MI Date of Birth Gender / / □ M □ F Patient Address City State Zip Phone #

Current Patient Medication(s) ICD-10 Dx Code(s)

Insurance Information □ Commercial □ Medicare □ Medicaid □ Workers Comp □ Patient Payment Auth □ Clinic Payment Auth Ins. Name: ID/Claim/Policy #:

D. URINE PRESUMPTIVE TESTING * Choose 1 Option - NONE or POCT or SCREEN Option * □ NONE □ POCT POCT Pos Neg N/T POCT Pos Neg N/T POCT Pos Neg N/T SCREEN Options Note: All Amphetamine □ □ □ Ecstasy/MDMA □ □ □ Opiate □ □ □ □ Specimen Validity positives Barbiturate □ □ □ EtOH □ □ □ Oxycodone □ □ □ □ Full Screen will undergo Benzodiazepine □ □ □ Methadone □ □ □ PCP □ □ □ NOTE: All positives will confirmation Buprenorphine □ □ □ Methamphetamine □ □ □ TCA □ □ □ undergo confirmation Cocaine □ □ □ Morphine □ □ □ THC □ □ □

E. CONFIRMATION TESTING * The Parent Dr ug O P or Metabolite O M May Be Included In Resulting * □ Confirm ALL medications □ Amphetamines Class □ Antidepressants Class □ Benzodiazepines Class □ Opiates Class □ OTC Class □ Amphetamine □ Amitriptyline OM □ Alprazolam OM □ Codeine OP OM □ Acetaminophen □ Methamphetamine OM □ Nortriptyline □ Chlordiazepoxide OM □ Hydrocodone OP OM □ Dextromethorphan □ D/L Isomer if (+) Parent □ Citalopram □ Diazepam OM □ Dihydrocodeine OP □ Cotinine □ Methylphenidate OM □ Doxepin OM □ Nordiazepam OP OM □ Hydromorphone OP □ Phentermine □ Duloxetine □ Temazepam OM □ Morphine OP OM □ Non-Benzo/Sleep Aids □ Fluoxetine □ Oxazepam □ Buprenorphine OM □ Zaleplon □ Anticonvulsants Class □ Imipramine OM □ Clonazepam OM □ Fentanyl OM □ Zolpidem OM □ Carbamazepine □ Desipramine □ Flurazepam OM □ Meperidine OM □ Gabapentin □ Olanzapine □ Flunitrazepam □ Methadone OM □ Other □ Pregabalin □ Paroxetine □ Lorazepam □ Naloxone □ Desomorphine □ Sertraline □ Midazolam OM □ Naltrexone □ Herbal-Dihydrokavain □ Alcohols Class □ Trazodone □ Triazolam OM □ Pentazocine □ Mitragynine Ethyl Glucuronide/Sulfate □ Venlafaxine OM □ Propoxyphene OM □ Desvenlafaxine □ Illicits Class □ Sufentanil □ Barbiturates Class □ Heroin (6-MAM) □ Tapentadol OM □ Butalbital □ Muscle Relaxants Class □ Benzoylecgonine (cocaine) □ Tramadol OM □ Pentobarbital □ Carisoprodol OM □ Ketamine OM □ Oxycodone OM □ Phenobarbital □ Meprobamate OP □ MDMA OM □ Oxymorphone □ Secobarbital □ Cyclobenzaprine □ MDA OP Provider-Defined Panels □ MDEA □ Urine Panel Code □ Oral Fluid Panel Code □ Designer Cathinones □ Synthetic Cannabinoids □ Phencyclidine (PCP) (Bath Salts) (K2 Spice) □ THC (carboxy-THC)

F. AUTHORIZATION * All signatures REQUIRED for processing * By signing this authorization, I authorize that payment(s) be made on my behalf to Crestar Labs for any services provided to me by Crestar Labs and any subsequent test ordered by my physician. I also allow the release of any medical information necessary to process all claims. Patient Signature ______Date ______By submitting this physician order for testing at Crestar Labs, I acknowledge the test(s) ordered are medically necessary and reasonable for the diagnosis and treatments rendered. I acknowledge only medically necessary testing should be ordered. As a provider, I acknowledge that the requested test(s) are medically necessary and a written order is contained in the patient’s records. If presumptive test(s) are performed, any request for definitive testing for drugs screened by LC/MS/MS is medically necessary for my patient. I acknowledge that this order is only for this specific patient and agree to have documented medical necessity to support the ordering of tests for this patient. Provider Signature ______Date ______

CLIA #44D2080511 2001 Campbell Station Pkwy., Suite C-2, Spring Hill, TN 37174 CLIA #21D2117107 12091 Somerset Ave, Princess Anne, MD 21853 CLIA #45D2098649 1651 N Collins Blvd, Richardson, TX 75080

A. CLINIC INFORMATION Clinic Name/Account # Clinic Street Address

Current Patient Medication(s) ICD-10 Dx Code(s)

Insurance Information □ Commercial □ Medicare □ Medicaid □ Workers Comp □ Patient Payment Auth □ Clinic Payment Auth Ins. Name: ID/Claim/Policy #:

CLIA #44D2080511 2001 Campbell Station Pkwy., Suite C-2, Spring Hill, TN 37174 CLIA #21D2117107 12091 Somerset Ave, Princess Anne, MD 21853 CLIA #45D2098649 1651 N Collins Blvd, Richardson, TX 75080

A. CLINIC INFORMATION Clinic Name/Account # Clinic Street Address

Current Patient Medication(s) ICD-10 Dx Code(s)

Insurance Information □ Commercial □ Medicare □ Medicaid □ Workers Comp □ Patient Payment Auth □ Clinic Payment Auth Ins. Name: ID/Claim/Policy #:

CLIA #44D2080511 2001 Campbell Station Pkwy., Suite C-2, Spring Hill, TN 37174 CLIA #21D2117107 12091 Somerset Ave, Princess Anne, MD 21853 CLIA #45D2098649 1651 N Collins Blvd, Richardson, TX 75080

M The below ICD-10 codes are typically associated with medical necessity for testing but do not guarantee coverage for any toxicology test. Providers are not required to use the below examples. Crestar Labs LLC does require multiple ICD10 codes which 1) are patient specific 2) prove the medical necessity of the ordered tests and 3) are a billable code of the highest specificity.

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) D70.9 Neutropenia, unspecified Endocrine, nutritional and metabolic diseases (E00-E89) E03.9 Hypothyroidism, unspecified E78.4 Other hyperlipidemia Mental, Behavioral and Neurodevelopmental disorders (F01-F99) F10.10 Alcohol abuse, uncomplicated F16.20 Hallucinogen dependence, uncomplicated F10.20 Alcohol dependence, uncomplicated F16.21 Hallucinogen dependence, in remission F11.10 Opioid abuse. uncomplicated F17.200 Nicotine dependence. unspecified. uncomplicated F11.20 Opioid dependence, uncomplicated F18.10 Inhalant abuse, uncomplicated F11.90 Opioid use, unspecified. uncomplicated F19.10 Other psychoactive substance abuse, uncomplicated F41.9 Anxiety disorder, unspecified F19.20 Other psychoactive substance dependence, uncomp F12.10 Cannabis abuse, uncomplicated F39 Unspecified mood (affective) disorder F12.120 Cannabis abuse with intoxication. uncomplicated F41.1 Generalized anxiety disorder F12.20 Cannabis dependence, uncomplicated F41.9 Anxiety disorder, unspecified F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated F43.10 Post-traumatic stress disorder. unspecified F14.90 Cocaine use, unspecified, uncomplicated F91.9 Conduct disorder, unspecified F15.10 Other stimulant abuse. uncomplicated Fl6.10 Hallucinogen abuse, uncomplicated F15.20 Other stimulant dependence. uncomplicated F90.9 Attention-deficit hyperactivity disorder, unspecified type Diseases of the nervous system (G00-G99) G47.00 Insomnia, unspecified G89.29 Other chronic pain G80.1 Spastic diplegic cerebral palsy G89.4 Chronic pain syndrome Diseases of the circulatory system (I00-I99) I10 Essential primary} hypertension Diseases of the digestive system (K00-K95) K59.00 Constipation, unspecified Diseases of the musculoskeletal system and connective tissue (M00-M99) M15.0 Polyosteoarthritis; Primary generalized (osteo)arthritis M54.12 Radiculopathy, cervical region M17.11 Unilateral primary osteoarthritis, right knee M54.15 Radiculopathy, thoracolumbar region M19.90 Unspecified osteoarthritis, unspecified site M54.16 Radiculopathy, lumbar region M25.512 Pain in left shoulder M54.2 Cervicalgia M25.561 Pain in right knee M54.40 Lumbago with sciatica, unspecified side M25.562 Pain in left knee M54.5 Low back pain M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M54.9 Dorsalgia, unspecified M51.36 Other intervertebral disc degeneration, lumbar region M79.7 Fibromyalgia M51.37 Other intervertebral disc degeneration, lumbosacral region M96.1 Postlaminectomy syndrome, not elsewhere classified Factors influencing health status and contact with health services (Z00-Z99) Z51.81 Encounter for therapeutic drug level monitoring Z79.891 Long term [current] use of opiate analgesic Z63.72 Alcoholism and drug addiction in family Z79.899 Other long term (current] drug therapy