DOB SEX M F Insurance Patient P - PDF document

1 DOB: ____/____/_____ SEX: M
DOB: ____/____/_____ SEX: M F Insurance Patient Pay Client Bill Worker's On my own volition I consent to the collection and testing of my specimen. I acknowledge that I am responsible for co-pays, deductibles and portions not covered by insurance. I assign to American Medical Laboratory LLC all insurance payment(s) made for all laboratory testing or services provided to me and direct same to represent me in grievances or appeals protocol concerning payment of these laboratory tests or services. I consent to the release of medical records deemed necessary to process all insurance claims. On my own volition I consent to the collection and testing of my specimen.I authorize the laboratory test(s) as ordered and also attest that each are both medically necessary and support the patient’s diagnosis. I acknowledge that each test ordered is a billable occurrence, and the medical record will be updated to distinctly reflect my order.POS NEG POS NEG POS NEG AMP BZO OPI BUP BAR COC OXY MDMA MTD THC PCP o Fentanylo Norfentanylo Naloxoneo Naltrexoneo Tapentadolo N-desmethyltapentadolo Sufentanilo O-desmethyltramadolo Meperidineo Normeperidineo Methadoneo EDDPo Propoxypheneo Buprenorphineo Norbuprenorphineo Fentanylo Norfentanylo Naloxoneo Naltrexoneo Tapentadolo N-desmethyltapentadolo Sufentanilo Zolpidem* Antidepressantso Amitriptylineo Nortriptylineo Desipramineo Desmethylcitalopramo Doxepino Fluoxetineo Hydroxybupropiono Imipramineo Sertraline* Pain Management Panelo Hydrocodoneo Hydromorphoneo Dihydrocodeineo Norhydrocodoneo Morphineo Codeineo Oxycodoneo Oxymorphoneo Noroxycodoneo Tramadolo O-desmethyltramadolo Meperidineo Normeperidineo Methadoneo EDDPo Propoxypheneo Buprenorphineo Norbuprenorphineo Fentanylo Norfentanylo Naloxoneo Naltrexoneo Tapentadolo N-desmethyltapentadolo Sufentanil 5130 W 125th Place, Alsip, Illinois 60803Phone: (708) 926-2116 Fax: (708)987-8741Email: support@americanmedicallab.com
Patient Name:___________________________DOB:__________________________________Collection Date:__________________________Collector’s Name:________________________ ACCOUNT INFORMATION PATIENT INFORMATIONBILLING INFORMATION ICD-10 DIAGNOSIS CODE(S)SPECIMEN COLLECTIONUrine Oral SwabDate Collected:______/______/______ Time:_____:_____ AM/PM Collector Name:_______________________SCREENING TEST WAS PERFORMED IN DOCTOR'SOFFICE (PLEASE RECORD RESULTS) CONFIRM ALL POSITIVES. PERFORM DEFINITIVE TEST FOR DRUG CLASS (SEE BACK FOR DETAILS )Alcohol Bath Salts Illicits StimulantsAnti-convulsants Barbiturates Muscle Relaxants/Sedatives Synthetic Cannabinoids Antidepressants Benzodiazepines PATIENT MEDICATIONS - Attach a List If NecessaryAdderall Citalopram Ephedrine Lortab Omeprazole Ritalin Vick's InhalerAdipex Claritin D Esomeprazole Lunesta Opana Robitussin AC VicodinAllegra-D Clonazepam Fentanyl Lyrica Oxycodone Roxicet VicoprofenAlprazolam Codeine Fioricet Meperidine Oxycontin Roxicodone VivitrolAmbien Concerta Oxymorphone Seroquel Amitriptyline Cyclobenzaprine Fluoxetine Pamelor SertralineXanaxAmphetamine Dalmane Flurazepam Methylphenidate Percocet Soma Zoloft Doxepin Hydrocodone Tramadol Zyrtec-DButalbital Duragesic Hydromorphone Pristiq Trazodone ___________NeurontinButrans Effexor Klonopin Prozac Ultram ___________NexiumCarisoprodol Elavil Lansoprazole Norco Pseudoephedrine Valium ___________ Celexa Endocet Lorazepam Nucynta Restoril Venlafaxine PHYSICIAN AUTHORIZATION : PATIENT AUTHORIZATION: Physician Signature __________________________ Date: _______________ Patient Signature __________________________ Date: ______________ AMERICAN MEDICAL LAB TOXICOLOGY LABORATORY REQUISITIONT0000 Confirm Medications TCA VyvanseWelbutrinZolpdemZubsolvSuboxoneSubsysSudafedPhenterminePregabalinPrevacidPrilosecAmrixAtivanBuprenorphineBupropionMidazolamMorphineMS ContinMSIRHorizantMeprobamateMethadoneFiorinalFlexerilGabapentinDexedrineDiazepamDilaudd MET PRESUMPTIVE TEST OPTIONS (Please choose only one ) PERFORM PRESUMPTIVE IMMUNOASSAY DRUG TEST AND CONFIRM ALL POSITIVES.Opiates / OpioidsOpioid Antagonists Last Name First Name MI Insurance Name Policy # Group # Comp/Auto/LOP Address:________________________________ Adjuster's Name:___________ Phone: ______________________ City, State, Zip Code : _____________________ Phone Number : __________________________ PLEASE ATTACH A COPY OF PATIENT FACE SHEET AND INSURANCE CARD _________________________________ _______________________________________________ SS# : ____-___-_____ Workers Comp/Auto/LOP- Date Of Injury:___/___/___ CI #:_______ T0000