CLIENT NAME AND ADDRESS COMPREHENSIVE TOXICOLOGY TEST REQUISITION Laboratory Director Dr. Xiaoli Chen, MD | CLIA # 39D1099562 Date Collected: Time Collected: 900 Town Center Drive, Ste H50, Langhorne, PA | TEL: (267) 212-2000 | FAX: (267) 212-2005 PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS PHONE (H) DATE OF BIRTH: (MM/DD/YYYY) SEX SOCIAL SECURITY NUMBER 06/ 1 8 /1990 INSURANCE INFORMATION I, the undersigned, understand that I am responsible for all co-pays and Commercial Medicare Medicaid Bill Patient Bill Client W/C (Date of Injury): deductibles, and for amounts not covered by insurance. By signing this authorization, I am acknowledging that payment(s) may be made on my behalf to Genesis Diagnostics for any services provided to me by Genesis NAME OF INSURED (IF DIFFERENT FROM PATIENT) PATIENT RELATIONSHIP TO INSURED: Diagnostics. I also allow the release of any medical information necessary to process this claim. SELF SPOUSE DEPENDENT PRIMARY INSURANCE NAME AND PLAN POLICY NUMBER Patient Signature Required Date ICD9-DX CODES EMPLOYER/GROUP NAME ORDERING PHYSICIAN'S SIGNATURE: (required for Medicaid) POINT OF CARE TESTING POCT SCREENING PANEL SPECIMEN TYPE Pos. Pos. Pos. Pos. Time Collected: AM / PM AMP COC MTD PCP URINE Date Collected: Saliva BAR MDMA OPI TCA ORAL SWAB Date Collected: BZO MET OXY THC BUP Temperature checked within 4 minutes of collection and is between ALL POCT NEGATIVE PEEL HERE 90 - 100 F or 32 - 38 C Yes No NO POCT PERFORMED CONFIRM POCT RESULTS PRESCRIBED MEDICATIONS PATIENT NOT ON ANY PRESCRIBED MEDICATION AMPHETAMINE FRISIUM CODEINE NUCYNTA ULTRAM ADDERALL HALCION DARVOCET NUMORPHAN VERSED CONCERTA KLONOPIN DARVON OPANA VICODIN DEXEDRINE LECTOPAM DEMEROL OPANA ER VICOPROFEN METHYLPHENIDATE LORAZEPAM DILAUDID OPANA IR TCA RITALIN MADAR DOLOPHINE OXY IR AMITRIPTYLINE BARBITURATES NITRAZEPAM DURAGESIC OXYCODONE ADAPIN OXAZEPAM AMYTAL EMBEDA OXYCONTIN AVENTYL PROSOM BUTALBITAL ENDOCET OXYMORPHONE ELAVIL RESTORIL BUTISOL EQUANIL PERCOCET NORPRAMIN ESGIC ROHYPNOL FENTANYL PERCODAN NORTRIPTYLINE FIORICET SERAX FENTORA PENTAZOCINE SURMONTIL FIORINAL STILNY HYDROCODONE PROPDXYPHENE TOFRANIL LUMINAL TEMAZEPAM HYDROMORPHONE ROXICET VIVACTIL NEMBUTAL VALIUM KADIAN ROXICODONE OTHERS SECONAL XANAX KETAMINE RYZOLT DEPAKOTE BENZODIAZEPINES MUSCLE RELAXANTS LORCET SUBLIMAZE MEPROBROMATE ALPRAZOLAM CARISOPRODOL LORTAB SUBOXONE MILTOWN ATIVAN FLEXERIL MEPERIDINE SUBUTEX CLONAZEPAM SOMA METHADONE TAPENTADOL DALMANE OPIATES / OPIOIDS MORPHINE TRAMADOL DIAZEPAM AVINZA MS CONTIN TYLENOL #3 EURODIN BUPRENORPHINE MSIR TYLENOL #4 FLUNITRAZEPAM BUTRANS NORCO TYLOX TEST(S) REQUEST * (See reverse for a description of each optional panel) Follow Customized Test Profile on File * Genesis Diagnostics provides health care professionals with the option of individual test selection, as opposed to pre-set panels of tests. Please identify the individual drugs and metabolites selected based on medical necessity. FOR LABORATORY Quantitive Confirmation of Drugs by LC/MS/MS USE ONLY Additional Tests Ordered COMP DRUG PROFILE THC BATH SALTS OTHER: Date Received: DRUG PROFILE A BARBITURATES K2 / SPICE OTHER: DRUG PROFILE B ALCOHOL (Etg, Ets) KAVA / KRATOM Time Received: AM / PM DRUG PROFILE C Genesis Diagnostics will confirm the validity of each specimen by analyzying creatinine levels, specific gravity, oxidants and pH. PHYSICIAN SIGNATURE I authorize the above laboratory test(s). I understand that as the practitioner, it is my responsiblility for determining the medical necessity of laboratory tests and for assigning and providing the specific ICD code(s) to support the medical necessity of all laboratory tests ordered. Physician Signature: Date: REV'20150410 COMPREHENSIVE DRUG PROFILE ST IM U LA N T S ILLIC IT S OPIODS OTHER PRESCRIPTIONS Bath Salts/Cathinones Amphetamine Cocaine Buprenorphine Dextromethorphan Butylone M ethamphetamine Benzoylecgonine Norbuprenorphine Ketamine Ethylone M ethylphenidate M DM A Fentanyl Norketamine M DPV Ritalinic Acid M DA Norfentanyl Gabapentin M ethylone Phentermine M DEA M eperidine Pregabalin M ethedrone BARBITURATES PCP Normeperidine Primidone M ephedrone Amobarbital THC M ethadone Zolpidem M DPBP Butabarbital OPIATES EDDP Zopiclone Naphyrone Butalbital 6-M AM Pentazocine Zaleplon Pentylone Pentobarbital M orphine Propoxyphene ANTIDEPRESSANTS PVP Phenobarbital Codeine Norpropoxyphene Amitriptyline KAVE / KRATOM Secobarbital Hydrocodone Tapentadol Desipramine Kavain BENZODIAZEPINES Hydromorphone Desmethyltapentadol Doxepin 7,8-dihydrokavain Alprazolam Norhydrocodone Tramadol Imipramine M iragynine Alpha-hydroxyalprazolam Oxycodone Desmethyltramadol Nortriptyline 7-hydroxymitragynine Bromazepam Oxymorphone Sufentanil Quetiapine SYNTHETIC CANNABINOIDES / Clonazepam Noroxycodone M USCLE RELAXANTS Ziprasidone SPICE 7-Aminoclonazepam Naloxone Carisoprodol Desmethylvenlafaxine Diazepam Naltrexone M eprobamate Fluoxetine A LC OHOL Nordiazepam Cyclobenzaprine Paroxetine Ethyl Glucuronide Oxazepam Sertraline Ethyl Sulfate(ETS) Temazepam Venlafaxine Flunitrazepam Flurazepam Lorazepam M idazolam Nitrazepam Triazolam DRUG PROFILE A - Minus TCA ST IM U LA N T S BENZODIAZEPINES ILLIC IT S OPIODS M USCLE RELAXANTS Amphetamine Alprazolam Cocaine Buprenorphine Carisoprodol M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine M eprobamate M ethylphenidate Bromazepam M DM A Fentanyl Cyclobenzaprine Ritalinic Acid Clonazepam M DA Norfentanyl Phentermine 7-Aminoclonazepam M DEA M eperidine OTHER PRESCRIPTIONS Diazepam PCP Normeperidine Dextromethorphan Nordiazepam M ethadone Ketamine Oxazepam OPIATES EDDP Norketamine Temazepam 6-M AM Pentazocine Gabapentin Flunitrazepam M orphine Propoxyphene Pregabalin Flurazepam Codeine Norpropoxyphene Primidone Lorazepam Hydrocodone Tapentadol Zolpidem M idazolam Hydromorphone Desmethyltapentadol Zopiclone Nitrazepam Norhydrocodone Tramadol Zaleplon Triazolam Oxycodone Desmethyltramadol Oxymorphone Sufentanil Noroxycodone Naloxone Naltrexone DRUG PROFILE B - Minus Sedative/Hypnotic Agent/Soma, Anticonvulsants, Barbiturates, TCA ST IM U LA N T S BENZODIAZEPINES ILLIC IT S OPIOIDS OTHER PRESCRIPTIONS Amphetamine Alprazolam Cocaine Buprenorphine Dextromethorphan M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine Ketamine M ethylphenidate Bromazepam M DM A Fentanyl Norketamine Ritalinic Acid Clonazepam M DA Norfentanyl OPIATES Phentermine 7-Aminoclonazepam M DEA M eperidine 6-M AM Diazepam PCP Normeperidine M orphine Nordiazepam M ethadone Codeine Oxazepam EDDP Hydrocodone Temazepam Pentazocine Hydromorphone Flunitrazepam Propoxyphene Norhydrocodone Flurazepam Norpropoxyphene Oxycodone Lorazepam Tapentadol Oxymorphone M idazolam Desmethyltapentadol Noroxycodone Nitrazepam Tramadol Naloxone Triazolam Desmethyltramadol Naltrexone Sufentanil DRUG PROFILE C - Minus Anticonvulsants, Barbiturates, TCA, Other Drugs ST IM U LA N T S BENZODIAZEPINES ILLIC IT S OPIOIDS M USCLE RELAXANTS Amphetamine Alprazolam Cocaine Buprenorphine Carisoprodol M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine M eprobamate M ethylphenidate Bromazepam M DM A Fentanyl Cyclobenzaprine Ritalinic Acid Clonazepam M DA Norfentanyl OPIATES Phentermine 7-Aminoclonazepam M DEA M eperidine 6-M AM Diazepam PCP Normeperidine M orphine Nordiazepam M ethadone Codeine Oxazepam EDDP Hydrocodone Temazepam Pentazocine Hydromorphone Flunitrazepam Propoxyphene Norhydrocodone Flurazepam Norpropoxyphene Oxycodone Lorazepam Tapentadol Oxymorphone M idazolam Desmethyltapentadol Noroxycodone Nitrazepam Tramadol Naloxone Triazolam Desmethyltramadol Naltrexone Sufentanil.