For more information, visit www.cordantsolutions.com, email [email protected] or call 1-855-895-8090.©2016 Cordant Health Solutions™. All rights reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.
Section 1: Practice InformationThe practice name, address and other information should be preprinted by Cordant Health Solutions™ in this section. Please confirm that all the information is complete and accurate. If this section is not preprinted, please discard the blank form and order new forms by calling 1-855-895-8090 and selecting the customer service option.
Section 2: Patient InformationFor the lab to process the specimen, accurate and complete patient information must be supplied. All information in this section is necessary to avoid any delays in processing. The patient name and date of birth must be clearly printed on the requisition. To streamline the process, a patient face sheet containing the remaining demographic information may be supplied in lieu of completing the items in this section. The patient must read the “All Patients” notice and sign and date where indicated.
Section 3: Specimen InformationPlease record the date and time of the specimen collection, along with the collector’s name. A collection time and date must be listed on every form. Please check the appropriate box to confirm that the temperature of the specimen is within range as indicated; otherwise, denote the actual temperature.
Section 4: Billing InformationPlease select one of the following billing options:
• Bill Ordering Agency—Your clinic, hospital or agency will receive an invoice for the testing requested. If you would like your clinic, hospital or ordering agency to receive an invoice for the testing, please mark Bill Ordering Agency.
If you do not want the testing services ordered to be billed to your clinic, hospital or agency, select one of the options below.
• Bill Patient—Bill the patient for the testing requested. Check this box for patients with no health insurance or who desire to pay out of pocket. Providers may also select financial hardship for patients who qualify (patients who are at or below 300% of the federal poverty threshold based on family size and income).
• Bill Insurance (INS)—Bill the insurance provided by the patient for the testing requested. If this box is checked, the patient information must be completed. Check the box where indicated and include a copy of the patient’s insurance card (front and back) and/or a face sheet if all insurance and patient information is up-to-date. In the case of workers’ comp testing, all sections of the Bill Insurance (INS) section must be filled out, including date of injury, claim number, state of injury and employer name/address, in order to avoid processing delays.
INSTRUCTION BOOKLETSCREEN & DIRECT DEFINITIVE URINE TESTINGRequisition “G” Form
SECTION 1
8610
0606
08 R
R D
onne
lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
SECTION 2
8610
0606
08 R
R D
onne
lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
SECTION 3
8610
0606
08 R
R D
onne
lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
8610
0606
08 R
R D
onne
lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
SECTION 4
If you are performing point-of-care or in-office testing utilizing point-of-care testing cups or an in-office analyzer, do not use this form; please see the Point-of-Care Urine Testing instruction booklet.
For more information, visit www.cordantsolutions.com, email [email protected] or call 1-855-895-8090.©2016 Cordant Health Solutions™. All rights reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.
8610
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lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
Section 5: Physician NoticeDiagnosis code(s) (ICD-10) and the name of the ordering physician are required on every form that is billed to insurance. Provide the appropriate diagnosis codes to support the medical necessity of all testing requested. For Medicare patients, submit a properly completed ABN (page 1 backer) signed by the patient for any test that you have reason to believe Medicare will not cover. Please supply the ordering physician’s NPI number if they are new to your practice and contact Cordant’s customer service department to add that physician to your account. A physician signature is highly recommended by all providers and required by ordering providers for MA, NJ, NY and PA Medicaid beneficiaries.
Section 6: Drug Test OrdersSection 6 contains two major sections, the “Immunoassay Screen Testing” section (❶) and the “Direct Definitive Testing” section (❷).
• Immunoassay Screen Testing—Placing a mark in the “Orders” column for any test or order group in this section will order a screen test that, if positive, will also reflex to a definitive test. If only a screen is desired, check the “DO NOT Confirm Positive Immunoassay Results” box where indicated (❸). Note that in this section there are “Order Group” check boxes (❹). If selected, all the drugs indicated within that order group will be tested (screen to direct definitive testing or screen only as previously indicated).
• If adulterant tests are required, select from the section provided. This will indicate that a screening test is needed for the selected adulterants. Validity testing is not processed as a direct definitive test.
• The tests listed under “Direct Definitive Testing” do not have a screen option and will have a direct definitive test performed utilizing LC-MS/MS or GC-MS/MS technology on all tests selected in this section.
• If testing at the analyte level is needed, write the needed test in the “Write in – Singular Analyte/Metabolite Test Orders” box as indicated (❺). Please discuss use of this section with your sales representative or with Cordant customer service to ensure that tests requested can be processed. Also, please reference page 2 of the back of the requisition form for a listing of the current analytes offered by Cordant.
8610
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lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
8610
0606
08 R
R D
onne
lley.
©20
16, A
ll rig
hts
rese
rved
. - D
RC
- 0
667
8610
0606
08
PR
OO
F 2
0
This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
GXXXXXX
Direction of feedthru customer’sprinter
FACE ALL PARTS; PERF AS SHOWN; SCREENS 10%, 15%, 20%, 30% & 35%
1A
1B
1C
1D
1E
1A
1B
1C
1D
1E
GXXXXXXGXXXXXX
PE
RF
PE
RF
LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
❸
❹
❶
❷
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SECTION 5
SECTION 6
For more information, visit www.cordantsolutions.com, email [email protected] or call 1-855-895-8090.©2016 Cordant Health Solutions™. All rights reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.
Section 7: Medication PrescribedCheck the box next to the name of the medication the patient is currently being prescribed. If testing is desired for these medications, check the “Quantitate Prescribed Medications” box in the header to order a direct definitive test for any marked medication. This can be used with or without section 6 filled out. If the patient does not have any medications prescribed, check the “No Medications Prescribed” box in the header. If a medication is not listed, write that medication in the space provided next to the “OTHER” option and check the associated box. If a current medications list is available, attach that to the requisition when submitting the testing to the lab with the specimen and check the “Prescribed Medications List Attached” box in the header. If you attach a current medications list, you still need to check the “Quantitate Prescribed Medications” box if you want those medications tested.
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This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
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LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
BACKERS: ABN AND DRUG CLASS COMPONENTSOn the back of page 1: Advanced Beneficiary Notice of Noncoverage
Explanation
Medical providers are required to present an Advance Beneficiary Notice of Noncoverage (ABN), also known as a waiver of liability, when offering patient services or items that the provider knows or has reason to believe Medicare will deny coverage for and therefore will not pay for the services provided.
Providers are not required to give the patient an ABN for services or items explicitly excluded from Medicare coverage (items that are never covered by Medicare even if medically necessary, such as hearing aids). In addition, ABNs apply only to patients covered by original Medicare, not Medicare private health plans (HMOs, PPOs or PFFSs).
If a provider has any reason to believe that the services provided will not be covered, the provider/patient must fill out the ABN form.
How to Complete the Form Provided
The patient or provider will need to fill out sections A, B and C (notifier, patient name and identification number). The notifier is the provider’s office. The patient name is the full name of the patient. The identification number is the patient ID number that is used at the provider’s facility to identify the patient.
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A. Notifi er:B. Patient Name: C. Identifi cation Number:
Advance Benefi ciary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.Medicare does not pay for everything, even some care that you or your health care provider havegood reason to think you need. We expect Medicare may not pay for the D. below.
D. E. Reason Medicare May Not Pay: F. Estimated Cost
WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you fi nish reading. • Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.G. OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the D. listed above. You may ask to be paid now, but Ialso want Medicare billed for an offi cial decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsiblefor payment, but I can appeal to Medicare by following the directions on the MSN. If Medicaredoes pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the D. listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
OPTION 3. I don’t want the D. listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare would pay.H. Additional Information:
I. Signature: J. Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Offi cer, Baltimore, Maryland 21244-1850.
Form Approved OMB No. 0938-0566Form CMS-R-131 (03/11)
This notice gives our opinion, not an offi cial Medicare decision. If you have other questions onthis notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.
SECTION 7
For more information, visit www.cordantsolutions.com, email [email protected] or call 1-855-895-8090.©2016 Cordant Health Solutions™. All rights reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.
In section D the patient/provider must list the services or items provided. Section E details the reason Medicare or another insurance provider may not pay for the services. Section F should be completed by the provider and include 100% Medicare Allowable Rates for the ordered tests.
In section G, the patient will need to select one of three options that confirm whether the patient wants the testing/services listed in section D and, if yes, how to handle the billing and payment.
Section H is for additional information and is not a required field.
The patient will need to sign and date this document in sections I and J.
On the back of page 2: Drug Class ComponentsAll the drug class components are located on the back for the provider’s reference. Each of the test options from section 6 is listed here and broken down to include the metabolites found via direct definitive testing. The components may vary from laboratory to laboratory and from specimen type to specimen type. Please contact your sales representative or customer service if there are any questions about testing capabilities.
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A. Notifi er:B. Patient Name: C. Identifi cation Number:
Advance Benefi ciary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.Medicare does not pay for everything, even some care that you or your health care provider havegood reason to think you need. We expect Medicare may not pay for the D. below.
D. E. Reason Medicare May Not Pay: F. Estimated Cost
WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you fi nish reading. • Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.G. OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the D. listed above. You may ask to be paid now, but Ialso want Medicare billed for an offi cial decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsiblefor payment, but I can appeal to Medicare by following the directions on the MSN. If Medicaredoes pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the D. listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
OPTION 3. I don’t want the D. listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare would pay.H. Additional Information:
I. Signature: J. Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Offi cer, Baltimore, Maryland 21244-1850.
Form Approved OMB No. 0938-0566Form CMS-R-131 (03/11)
This notice gives our opinion, not an offi cial Medicare decision. If you have other questions onthis notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.
To order additional forms, call:
1-855-895-8090(Select the customer service option.)
Cordant has created a separate document for information on processing, packing and shipping specimens.
Please contact Cordant at this number for a copy of these instructions.
PROOF
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ALCOHOL BIOMARKERethyl glucuronide
ethyl sulfate
ALCOHOLSethanol
AMPHETAMINESamphetaminemethamphetaminephentermine
ephedrine
ANTIDEPRESSANTS, NOT OTHERWISE SPECIFIED13chlorophenylpiperazinenefazodonetrazodonevenlafaxinedesmethylvenlafaxinebupropion
hydroxybupropion
ANTIDEPRESSANTS, SEROTONERGIC CLASScitalopramdesmethylcitalopramduloxe� nefl uoxe� nefl uvoxaminenorfl uoxe� nenorsertralineparoxe� nesertraline
vilazodone
ANTIDEPRESSANTS, TRICYCLIC & OTHER CYCLICALS8hydroxyamoxapineamitriptylineamoxapineclomipraminedesipraminedesmethylclomipraminedesmethyldoxepindesmethylmirtazapinedoxepinimipraminemapro� linemirtazapinenortriptylineprotriptyline
trimipramine
ANTIPSYCHOTICS, NOT OTHERWISE SPECIFIED7hydroxyque� apine9hydroxyrisperidonearipiprazoleclozapinedehydroaripiprazoledesmethylclozapinedesmethylolanzapinenorque� apineolanzapineque� apinerisperidone
haloperidol
BARBITURATESbutalbitalphenobarbitalsecobarbitalamobarbital
pentobarbital
BENZODIAZEPINES7aminoclonazepamalphahydroxyalprazolamalprazolamlorazepamnordiazepamoxazepamtemazepamdiazepamclonazepam
chlordiazepoxide
BUPRENORPHINEbuprenorphine
norbuprenorphine
CANNABINOIDS, NATURALTHC Metabolite
THC
CANNABINOIDS, SYNTHETICJWH-073 N-propanoic acidJWH-200 5-hydroxyindoleJWH-203 n-pentanoic acidJWH-210 N-(5-hydroxypentyl)JWH-018 N-(5-hydroxypentyl)JWH-018 N-pentanoic acidJWH-019 N-(6-hydroxyhexyl)JWH-073 N-(4-hydroxybutyl)JWH-073 N-butanoic acidJWH-081 N-5-hydroxypentylJWH-122 N-5-hydroxypentylJWH-250 N-(5-hydroxypentyl)JWH-398 N-pentanoic acidAKB-48 n-pentanoic acidAM-2201 N-(4-hydroxypentyl)AM-694 n-pentanoic acid
MAM2201 n-pentanoic acid
5-Fluoro-PB-22 carboxyindolePB-22 3-CarboxyindoleBB-22 3-CarboxyindoleRCS-4 N-(5-hydroxypentyl) phenol, M10RCS-4 N-(5-hydroxypentyl)UR-144 N-pentanoic acidUR-144 pyrolysis n-pentanoic acidXLR-11 6-hydroxyindoleXLR-11 N-(4-hydroxypentyl)AB-PINACA N-(4-hydroxypentyl)AB-FUBINACA metaboliteAB-PINACA pentanoic acidADB-PINACA pentanoic acidADBICA n-pentanoic acid
5-Fluoro AB-PINACA N-(4-hydroxypentyl)
CARISOPRODOLcarisoprodol
meprobamate
COCAINEbenzoylecgonine
cocaine
CYCLOBENZAPRINEcyclobenzaprine
FENTANYLacetylfentanylacetylnorfentanylfentanyl
norfentanyl
GABAPENTINgabapen� n
HEROIN METABOLITE6acetylmorphine
KETAMINE AND NORKETAMINEketamine
norketamine
KRATOM7hydroxymitragynine
mitragynine
METHADONEeddp
methadone
METHYLENEDIOXYAMPHETAMINESmdamdea
mdma
METHYLPHENIDATEmethylphenidate
ritalinic acid
NICOTINE/COTININEco� nine
nico� ne
OPIATEScodeinehydrocodonehydromorphonemorphine
norhydrocodone
OPIODS AND OPIATE ANALOGS6betanaltrexoldextromethorphandextrorphanmeperidinenaloxonenaltrexonenormeperidine
pentazocine
COMPONENTS MAY VARY FROM LABORATORY TO LABORATORY AND FROM SPECIMEN MATRIX TO SPECIMEN MATRIX.
OXYCODONEnoroxycodoneoxycodone
oxymorphone
PHENCYCLIDINEphencyclidine
PREGABALINpregabalin
PROPOXYPHENEnorpropoxyphene
propoxyphene
SEDATIVE HYPNOTICS NONBENZODIAZEPINESzaleplonzolpidem
zopiclone
STEREOISOMER ENANTIOMER ANALYSISmethamphetamine
STIMULANTS, SYNTHETICEthyloneButyloneMethedroneMethylenedioxypyrovaleroneNaphyroneMephedroneMethyloneMethcathinoneFlephedroneα-PBPα-PVP
DMAA
TAPENTADOLtapentadol
TRAMADOLdesmethyltramadol
tramadol
DRUG CLASS COMPONENTS
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This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.
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LABORATORY USE ONLY
Ver 4 Rev. 1.0 SHS-001 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY
PlaceOverCap
Donor Ini� alsDate Collected
Collector Ini� als
1. PRACTICE INFORMATION 6. DRUG TEST ORDERS
AFFIX BARCODE LABEL TO SPECIMEN CONTAINER
LABORATORY URINE SCREEN AND DIRECT DEFINITIVE TESTING REQUISITION
To order, place an X or otherwise mark in the sec ons below. Selec ng Order Group will order all listed tests within bolded sec on.
7. CURRENT PRESCRIBED MEDICATIONS No Medica ons PrescribedQuan tate Prescribed Medica onsPrescribed Medica onsList A ached
Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.
PROOF2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK
All Pa ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for anycopay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.
Physician Signature:
(Last):
(First): (M.I.):
Date of Birth: Phone#:M F/ /
SS#: Pa� ent ID#:
Address, City, State, Zip:
Pa� ent Signature: Date:
/ /State ofInjury:
Date Collected:MM/DD/YYYY
Time: : AM PM
Collector’s Name:
3. SPECIMEN INFORMATION
Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F
5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.
ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.
Diagnosis Code(s): Ordering Physician:
4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE
Bill Ordering Agency
Medicare Medicaid
Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� achedCommercial INS Motor Vehicle Accident (MVA)
INS NAME: Policy / ID #
Claim Address:
MVA/WC Claim #:
Employer Name:
Employer Address:
/ /
If no, Actual Temp:YES NO
Bill Pa ent: Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.
Self-Pay Financial Hardship
Date ofInjury:
Employer Phone #:
Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)
Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)
Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)
Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)OTHER ____________________________OTHER ____________________________OTHER ____________________________
Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)
Immunoassay Screen Tes ng
Direct Defi ni ve Tes ngAn� depressants, not otherwise specifi edAn� depressants, serotonergic classAn� psycho� csCyclobenzaprineD/L Methamphetamine**KetamineKratom (Mitragynine)MethylphenidateOpioids and Opiate AnalogsSeda� ve hypno� cs S� mulants, synthe� c (Bath Salts)Tapentadol
Opioid GroupOpiatesOxycodone/OxymorphoneBuprenorphineFentanylMethadoneTramadolIllicit and Drug of Abuse GroupCannabinoids, natural (THC)CocaineEcstasy (MDA, MDEA, MDMA)Heroin metabolite (6-acetylmorphine)PhencyclidineCommon Therapeu csAmphetaminesAn� depressants, tricyclic & other cyclicalsBarbituratesBenzodiazepinesCarisoprodolGabapen� nPregabalinSpecialty Tes ngAlcohol (Ethanol)Alcohol Biomarkers (EtG/EtS)Cannabinoids, synthe� cNico� ne (co� nine) PropoxypheneAdulterantsValidity Group – Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity
Order Group*
Order Group*
Order Group*
DO NOT Confi rm Posi ve Immunoassay ResultsOrders
DRUG CLASS COMPONENTS ON BACK*If posi� ve quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamine box and the D/L Methamphetamine box.
Write in - Singular Analyte/Metabolite Test Orders
Workers’ Comp (WC)
SAMPL
E
D O EJ A N E
Jane Doe 6/2/2016
8910 Some Street, Some Town, CO 88888
67890 Any Street, Any Town, USA 98765
1 2 3 4 5 6 7 8 9 A B C D E F1 2 3 4 5 6 7 8 90 01 1 1 9 8 0 5 5 5 5 5 5 5 5 5 5
0 6 0 2 2 0 1 6 0 2 3 0T I M C O L L E C OT R
12345678910Big Insurance
A12.345 Dr. Who
Sample Name 1234 Any Street, Any Town, CO 88888 Account# XXXXX
Dr. Who