PATIENT INFORMATION PRACTICE INFORMATION ____________________________________ _____________________________________ _______ ________________________ __________________ Last Name First Name MI Facility/Group Referring Physician ________/________/________ Social Security: _________-_________-________ ☐ Male ☐ Female ___________________________________________ Date of Birth Address NPI Provider Nr. __________________________________________________________________ Address DIAGNOSTIC CODES (ICD-10 codes): _____________________________ ☐ Self-Pay (attach Information) ☐ Commercial Insurance (attach copy) ☐ W/C (Date of Injury): ____________ ☐ Medicare (attach copy of Insurance) I certify that I have voluntarily provided a fresh unadulterated urine/dried blood/oral fluid specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. I authorize lab to release the results of this testing to the ordering physician. I also authorize lab to bill my insurance provider and to receive payment of benefits for the tests ordered by my physician. I further authorize lab and the ordering physician to release to my insurance provider any medical information necessary to process this claim. I acknowledge that lab may be an out-of-network facility with my insurance provider. Patient Signature (or Legal Guardian): ___________________________________________________________________________ Date: _______________ TEST PANELS (please check desired specimen type & drugs/drug classes for testing): ☐ URINE SPECIMEN ☐ DRIED BLOOD SPOT SPECIMEN (at least 3 tips required, recommend collecting all 4) ☐ ORAL FLUID SPECIMEN o Gabapentin (Neurontin) o MDA (Tenamfetamine) ☐ URINALYSIS/VALIDITY TESTING (Urine) ☐ 3. ANTI-PSYCHOTICS o Lamotrigine (Lamictal) o MDEA (“Eve”) o Aripiprazole (Abilify) ☐ TEST FOR ALL CLASSES BELOW (1-14) o Levetiracetam (Keppra) o MDMA (Ecstasy, “Molly”) o Chlorpromazine (Thorazine) o Oxcarbazepine (Trileptal) o MDPV (Bath Salts) ☐ 1. ANALGESICS / OPIATES o Clozapine (Clozaril) o Pregabalin (Lyrica) o Mephedrone (Bath Salts) o Acetaminophen (Tylenol) o Fluphenazine (Permitil) o Tiagabine (Gabitril) o Methamphetamine (Meth) o Buprenorphine (Butrans) o Haloperidol (Haldol) o Valproic Acid (Depakote) o Methylone (Bath Salts) o Butorphanol (Stadol) o Olanzapine (Zyprexa) o Zonisamide (Zonegran) o Mitragynine (Kratom) o Codeine (Tylenol #3) o Quetiapine (Seroquel) o PCP (Phencyclidine) ☐ 7. MUSCLE RELAXANTS o Fentanyl (Duragesic, Actiq) o Risperidone (Risperdal) o THC (Marijuana) o Hydrocodone (Norco, Vicodin) o Thioridazine (Mellaril) o Baclofen (Liorsel) o U-47700 (Synthetic Opioid) o Hydromorphone (Dilaudid) o Ziprasidone (Geodon) o Carisoprodol (Soma) o Cyclobenzaprine (Flexeril) ☐ SPICE CANNABINOIDS o Ketamine (Ketalar) ☐ 4. ANTI-DEPRESSANTS o Levorphanol (Levo-Dromoran) o Methocarbamol (Robaxin) o 5-Fluoro NPB-22 o Amitriptyline (Elavil) o AB-FUBINACA o Meperidine (Demerol) ☐ 8. STIMULANTS o Bupropion (Wellbutrin) o AM-2201 o Methadone (Methadose, Dolophine) o Citalopram (Celexa) o Amphetamine (Adderall) o Morphine (MS Contin, Kadian, o FDU-PB-22 o Clomipramine (Anafranil) o Caffeine (Viviran, Cafcit) o HU-210 Duramorph, Avinza) o Desipramine (Norpramin) o Ephedrine (Bronkaid) o Oxycodone (Percocet, Oxycontin) o JWH-019 o Desvenlafaxine (Pristiq) o Methylphenidate (Ritalin) o JWH-073-4-Hydroxybutyl o Oxymorphone (Opana) o Doxepin (Silenor, Prudoxin) o Lisdexamfetamine (Vyvanse) o Propoxyphene (Darvon) o JWH-081 o Duloxetine (Cymbalta) o Ritalinic Acid (Methylphenidate) o JWH-122 o Tapentadol (Nucynta) o Fluoxetine (Prozac) ☐ 9. DECONGESTANTS o JWH-18-5-Pentonic Acid o Tramadol (Ultram) o Fluvoxamine (Luvox) o Dextromethorphan (Robitussin) o JWH-18-5-Pentanyl ☐ 2. BENZODIAZEPINES o Imipramine (Tofranil) o Pseudoephedrine (Sudafed) o JWH-250-5-OH-Pentanyl o Alprazolam (Xanax, Niravam) o D-L-Kavain, Yangonin, o MMB-CHMICA o Buspirone (Buspar) Methysticin (Kava) ☐ 10. APPETITE STIMULANT o Chlordiazepoxide (Librium) o Mirtazapine (Remeron) o Marinol (Dronabinol Extract) ☐ 13. BARBITURATES o Clobazam (Onfi) o Nortriptyline (Pamelor) o Phentermine (Suprenza) o Amobarbital (Amytal) o Clonazepam (Klonopin) o Paroxetine (Paxil, Pexeva) o Butabarbital (Butisol) ☐ 11. ANTIDOTES o Diazepam (Valium, Diastat) o Sertraline (Zoloft) o Butalbital (Axotal) o Naloxone (Evzio) o Estazolam (Prosom) o Trazodone (Oleptro) o Phenobarbital (Luminal) o Flunitrazepam (Rohypnol) o Venlafaxine (Effexor) o Naltrexone ( Revia, Vivitrol) o Pentobarbital (Nembutal) o Secobarbital (Seconal) o Flurazepam (Dalmane) ☐ 5. DEPRESSANTS ☐ 12. ILLICITS o Lorazepam (Ativan) o Zaleplon (Sonata) o 6-MAM (Heroin) ☐ 14. DIRECT BIOMARKERS o Midazolam (Versed) o Zolpidem (Ambien) o Acetyl-Fentanyl o Cotinine (Nicotine) o Oxazepam (Serax) o Zopiclone (Zimovane, Lunesta) o Alpha-PVP (“Flakka”) o ETG (Ethanol Metabolite) o Prazepam (Centrac) o Carfentanil (Wildnil®) o ETS (Ethanol Metabolite) o Temazepam (Restoril) ☐ 6. ANTI-CONVULSANTS o Cocaine (“Coke”) o Triazolam (Halcion) o Carbamazepine (Tegretol) o DMT (Tryptamine) SAMPLE HANDLING The following MUST be completed (check all that apply): Desired Drug Panels marked above. Separate Medication List provided. Time Collected: __________ AM/PM Date Collected: __________ Minimum of 5 mL specimen provided in Urine Test Cup (seal lid!) or Minimum of 0.25 mL specimen provided in Oral Fluid Device Collected by: ___________________________________________ Urine/Saliva device sealed tightly & bagged in BIOHAZARD BAG with no spill or CleanAssure™ test by dried blood spot (use 4-tip Microsampling Kit). CleanAssure™ specimen must be shipped sealed in foil bag with desiccant. AUTHORIZATION & ATTESTATION By signing below, I authorize Alcala Testing to perform LC-MS/MS testing for qualitative and quantitative confirmation of positive and negative results. I attest that the requested testing is medically necessary and appropriate based on the patient’s diagnosis and treatment plan. I have personally completed the diagnosis codes above to indicate the accurate diagnosis for this patient. I have not already provided this testing on the date of collection. Physician Signature: ________________________________________________________ Date: ___________________________ Form_DBS_URI_OF-DISCOVER-001 Rev 5. 03/2020 COPYRIGHT © – ALCALA LABS .