1901 East Linden Avenue, Suite 4, Linden, NJ 07036
Patient Signature: Authorized Provider Signature:
I have read the ABN Notice. If Medicare denies payment, I agree to pay for the identified test(s).
ACCOUNT
BILLING INFORMATION RELATIONSHIP
Insurance Company
Member #
Patient
Client
Medicare
Medicaid
Insurance Auto Injury
Workers Comp.
Other(please attach)
Self Spouse Child
Other
ABN NOTICE
Patient Signature
QUANTITATIVE ANALYSIS
ADDITIONAL SUBSTANCES
PATIENT AUTHORIZATION
F M DOB
First Name
Middle Name
State: Zip:City: Pt. ID
Phone:
PATIENT INFORMATION
SSN:
Last Name
Address
I certify that I have voluntarily provided a fresh and unadulterated urine specimen for analytical testing. The information on this form and on the label a�xed to the specimen cup is accurate. I authorize ACCU Reference Medical Lab to release the results of this testing to the treating authorized healthcare provider or facility. I hereby authorize my insurance plan to be billed and bene�ts to be paid directly to ACCU Reference Medical Lab for services I received. I acknowledge that ACCU Reference Medical Lab may be an out-of-network provider with my insurer. I am also aware that in some circumstances my insurer will send the payment directly to me. I agree to endorse insurance check and forward it to ACCU Reference Medical Lab within 30 days of receipt. Failure to do so may result in my account being forwarded to Collections and reported to a Credit Bureau. I understand that ACCU Reference Medical Lab may use my specimen and any testing performed on that specimen, for research, development and potential publication purposes, so long as the information has been properly de-identi�ed pursuant to law.
DIAGNOSIS CODES (ICD-9)
Unspecified drug dependenceLong-term (current) use of other medicationsEncounter for therapeuticdrug monitoring
304.90V58.69
V58.83
Observation for other suspected mental condition
V71.09
T: (877) 733-4522 F: (908) 474-0032 www.accureference.com
POINT-OF-CARE TEST/ ORDER CONFIRMATION TESTS
CURRENT MEDICATIONS
ACTIQ ADDERALL ALBUTEROL ALPRAZOLAM AMITRIPTYLINE AMPHETAMINE ATENOLOL ATIVAN AVINZA BACLOFEN BUPRENEX BUPRENORPHINE BUTALBITAL CARISOPRODOL CELEBREX CELEXA CHLORDIAZEPOXIDE CLONAZEPAM CLONIDINE CODEINE CYMBALTA DARVOCET DARVON DEMEROL DESOXYN
DEXEDRINE DIAZEPAM DILAUDID DOLOPHINE DURAGESIC DURAMORPH EFFEXOR ELAVIL ENDOCET EQUANIL FENTANYL FLEXERIL FlORICET FlORINAL GABAPENTIN HALCION HYCODAN HYDROCODONE HYDROMORPHONE KADIAN KLONOPIN LEXAPRO LlBRIUM LlDODERM LlPITOR
LORAZEPAM LORCET LORTAB LUNESTA LYRICA MARINOL MAXIDONE MEPROBAMATE MEPROSPAN METFORMIN METHADONE METHYLPHENIDATE METOPROLOLMIDAZOLAMMILTOWN MOBIC MORPHINE MS CONTINMSIRNEMBUTALNEURONTINNEXIUMNORCONUCYNTA NUMORPHAN
OPANAOXAZEPAM OXYCODONE OXYCONTINOXYMORPHONEPAXILPERCOCETPERCODANPERCOLONEPHENERGANPHENOBARBITALPREGABALINPREVACIDPRILOSEC PROPOXYPHENEPROZACRA MORPHRESTORILRITALINROBAXINROXANOLROXICODONESATIVEXSERAXSKELAXIN
SOMASUBOXONESUBUTEXTEMAZEPAMTOPAMAXTRAMADOLTRANXENETRAZODONETRIAZOLAMTUSSIONEXTYLENOL #3 TYLENOL #4TYLENOL #5TYLOXULTRACETULTRAMVALIUMVERSEDVICODINVlCOPROFENVYVANSEWELLBUTRINXANAXZYDONE
SPECIMEN VALIDITY TESTING
SPECIAL INSTRUCTIONS:
ADDITIONAL SUBSTANCES (SCREEN TO CONFIRM)P361PCANX172
326852P312
6-MAM (HEROIN METABOLITE)MARIJUANA METABOLITE (THC)ETHANOL
FENTANYLMDMA (ECSTASY)TRAMADOL
OPIATESOXYCODONEPHENCYCLIDINE
PROPOXYPHENESPECIMEN VALIDITY
10 PANEL (DRUG SCREENS WITH REFLEX TO CONFIRMATION)
AMPHETAMINEBARBITURATESBUPRENORPHINE
BENZODIAZEPINESCOCAINEMETHADONE
1125
TOXICOLOGY TEST REQUISITION SPECIMEN COLLECTION / INFORMATION
Temperature read within 4 min.and is in range of 32.2_37.3°C (90 _100°F)
YES NO if NO: Actual Temp.:
Date: Time:ampm
CUSTOM PANELS
MEDICATION OR DRUG CONF. POS(+) CONF. NEG(-) CONF. POS(+) CONF. NEG(-)MEDICATION OR DRUG11311134485114411351133
BZOBARCOCTHCMETOPI
BENZODIAZEPINEBARBITURATESCOCAINEMARIJUANAMETHAMPHETAMINEOPIATES
113211374861135A4681147
MTDOXYPCPAMPPPX BUP
METHADONEOXYCODONEPHENCYCLIDINEAMPHETAMINES PROPOXYPHENEBUPRENORPHINE
6-MAM (HEROINE METABOLITE)
ALCOHOLAMPHETAMINES ANTICONVULSANTBARBITURATESBENZODIAZEPINEBUPRENORPHINECATHINONES (BATH SALT)COCAINE
FENTANYLMARIJUANA METABOLITE (THC)MEPERIDINE PANELMETHADONEMETHAMPHETAMINEMDMA (ECSTASY)MUSCLE RELAXANTNICOTINE METABOLITEOPIATES
OXYCODONEPHENCYCLIDINE (PCP) SLEEP AIDSTIMULANTSYNT. MARIJUANA (SPICE) TAPENTADOL TRAMADOL TRYCYCLIC ANTIDEPRES.
1145ALCO113517151134113111471717485NITRITES, PH URINE, SPECIFIC GRAVITY, CREATININE640/685
48711441722113211351130171617141133
1137486171817201711172111461719640/685
COMPREHENSIVE QUANTITATIVE ANALYSIS (THIS TEST INCLUDES ALL COMPONENTS LISTED BELOW) 2676
ar tox oAR TOX 0000001
SVT
877-733-4522
6-MAM (HEROINE METABOLITE)6-MAMALCOHOLETGETSAMPHETAMINESAMBHETAMINEMETHAMPHETAMINEMETHYLPHENIDATEANTICONVULSANTGABAPENTINPREGABALINBARBITURATESSECOBARBITALPHENOBARBITALBUTALBITALBENZODIAZEPINEALBROZALAMALPHA-HYDROXYALPROZALAMNORDIAZEPAMOZAZEPAMTEMAZEPAMCHONAZEPAM7-AMINOCLONAZEPAMLORASEPAMFLURAZEPAM2-HYDROXYETHYL FLURAZEPAMDESALKYLFLYRAZEPAMMIDAZOLAMALPHA-HYDROXYMIDAZOLAMCHLORDIAZEPROXIDEDIAZEPAMFLYNITRAZEPAM
1145
ALCO
1135
1715
1134
1131
BUPRENORPHINENALOXONEBUPRENORPHINENORBUPRENORPHINECATHINONES (BATH SALT)MDPVMETHEDRONEMETHYLONEPENTEDRONECOCAINECOCAINE METABOLITEFENTANYLFENTANYLNORFENTANYLMARIJUANA METABOLITE (THC)THCMEPERIDINE PANELMEPERIDINENORMEPERIDINEMETHADONEMETHADONEEDDPMETHAMPHETAMINEAMPHETAMINEMETHAMPHETAMINEMETHYLPHENIDATEMDMA (ECSTASY)MDMAMETHYLENE DIOXYL ETHYL AMPHETAMINEMETHYLENE DIOXY AMPHETAMINE
1147
1717
485
487
1144
1722
1132
1135
1130
MUSCLE RELAXANTCARISOPRODOLMEPROBAMATECYCLOBENZAPRINENICOTINE METABOLITECOTININEOPIATESCODEINEMORPHINEHYDROCODONEHYDROMORPHONENORHYDROCODONEDIHYDROCODOXYCODONEOXYCODONEOXYMORPHONENOROXYEODONEPHENCYCLIDINE (PCP)PHENCYCLIDINE (PCP)SLEEP AIDZALEPLONZOLPIDEMSTIMULANTMETHYLPHENIDATERITALINIC ACIDSYNT. MARIJUANA (SPICE)JWH-073 N-(5 HYDROXYBUTYL)JWH-250 5-HYDROXYPENTYLJWH-018 N-4HYDROXYPENTYLJWH-018 PENTANOIC ACID
1716
1714
1133
1137
486
1718
1720
1711
QUANTITATIVE ANALYSISCOMPREHENSIVE QUANTITATIVE ANALYSIS (THIS TEST INCLUDES ALL COMPONENTS LISTED BELOW) 2676
SPECIMEN HANDLING REQUIREMENTS:SPECIMEN VOLUME - 30ML PREFERRED TRANSPORTED IN SPECIMEN TRANSPORT VIAL (PACKED IN COLLECTION CUP) / 30ML MINIMUM TRANSPORTED IN SPECIMEN TRANSPORT VIAL
ACCEPTABLE SAMPLES - 30ML PREFERRED TRANSPORTED IN SPECIMEN TRANSPORT VIAL / 30ML MINIMUM TRANSPORTED IN SPECIMEN TRANSPORT VIAL
TRANSPORT - ROOM TEMPERATURE
SPECIMEN STABILITY - ROOM TEMPERATURE FOR 5 DAYS, REFRIGERATED 7 DAYS, FROZEN 30 DAYS
SPECIMEN REJECTION - PRESERVED SAMPLES
TAPENTADOLTAPENTADOLN-DESMETHYLTAPENTADOL TRAMADOLTRAMADOLO-DESMETHYLTRAMADOL TRYCYCLIC ANTIDEPRESSANTAMITRIPTYLINENORTRYPTILINEDOXEPINDESIPRAMINEIMIPRAMINESPECIMEN VALIDITY TESTINGPHCREATININESPECIFIC GRAVITYNITRITES
1721
1146
1719
640/685
Test Authorization for Mass Spectrometry (MS):Please perform MS quantification on any urine drug tests that initially test positive. I understand this is an additional procedure, and this order is to facilitate the prescription/ therapeutic drug monitoring program required as a condition of the treatment program prescribes for my patients.
Patient Billing Policy:Accu Reference Medical Lab (ARML) accepts payments from the majority of insurance companies; although ARML reserves the right to reject unacceptable settlement offers from non-contracted insurance plans. Patient billing will occur for insurance deductibles, co-payments, and co-insurance amounts deems by the insurance company to be the responsibility of the patient. Patient billing will also occur for the entire cost of the services if no coverage agreement is in place between ARML and the insurance company, or if the insurance company has determined that no coverage is available for the ARML test. ARML will work with patients on an individual basis to establish payment options on any outstanding balances through the Financial Assistance Program. All invoices include a toll-free number for patients to contact ARML directly with questions or concerns. Uninsured patients will be billed directly at special rates. I authorize disclosure by ARML of lab results directly to the worker’s compensation carriers, as applicable.
Practitioner Acknowledgment:In my professional judgment, the tests I order ARE MEDICALLY NECESSARY. I also understand that my order and a requisition are required for each specimen sent to Accu Reference Medical Lab. If any member of my staff requests confirmation testing or additional tests not covered by this form, I understand that the patient’s medical record must clearly reflect my order for such confirmations and tests.
