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.