Practice Name: ____________________________________________________
Address: _________________________________________________________
E-mail: ___________________________________________________________
ALL ORANGE AREAS ARE REQUIRED.
Phone: ____________________________ Fax: ___________________________
Patient Information
Comprehensive Panel
Name (Last, First, MI):
Sex:
☐ Male
☐ Female
_________________________________________________________________
Date of Birth (MM/DD/YYYY): _____________________________________
**Include copies of the patient’s demographic face sheet or write-in details below.**
Street Address: ___________________________________________________
City: ______________________________ State: __________ Zip: __________
(includes all of the tests below,
except drug class screen)
☐ Comprehensive Clinical Toxicology Panel
Benzodiazepine Panels (LC-MS/MS)
☐ Benzodiazepines I:
 Alprazolam and
alpha-OH-hydroxyalprazolam
 Chlordiazepoxide
 Clonazepam and
7-aminoclonazepam
 Midazolam
☐ Benzodiazepines II:
 Diazepam
 Nordiazepam
 Lorazepam
 Oxazepam
 Temazepam
 Triazolam and
Medical Record/Patient ID#: _______________________________________
Place of Service:
☐ Hospital Inpatient
☐ Hospital Outpatient
☐ Ambulatory Surgical Center
☐ Office/Non-Hospital
Billing Information
Bill
to:
**
☐ Insurance
☐ Patient
☐ Client
☐ Medicare/Medicaid
An Advance Beneficiary Notice of Noncoverage form must be completed and
**Include copies of both sides
of the patient’s insurance card(s).**
attached for
all Medicare patients.**
**
An Advance Beneficiary Notice of Noncoverage form must be completed and
attached for all Medicare patients.**
alpha-hydroxytriazolam
Opioid Panels (LC-MS/MS)
☐ Opioids I:
 Codeine
 Morphine
 Hydrocodone
 Hydromorphone
 Oxycodone
 Oxymorphone
☐ Opioids III:
 Tapentadol
 Tramadol and
O-desmethyltramadol
☐ Opioids IV:
 Methadone
 EDDP
☐ Opioids II:
 Buprenorphine and
norbuprenorphine
 Fentanyl and norfentanyl
Insurance Name: __________________________________________________
Other Assays (LC-MS/MS)
Insurance Address: _______________________________________________
☐ Amphetamines:
 Amphetamine
 Methamphetamine
 MDMA
Policy #: _________________________________________________________
 MDA
Group/Plan #: ____________________________________________________
 MDEA
☐ Ethanol Biomarker Panel:
 Ethyl glucuronide
 Ethyl sulfate
☐ Barbiturates:
 Butalbital
 Phenobarbital
Subscriber DOB: _________________________________________________
 Pentobarbital
Relationship to Subscriber:
☐ Self
☐ Spouse
☐ Dependent
☐ Cannabinoids:
 11-nor-9-carboxy-delta-9-THC
Secondary Insurance:
☐ Yes
☐ No
**Attach all of the patient’s secondary insurance information to this requisition. **
☐ Cocaine:
 Cocaine
Provider Information
 Benzoylecgonine
 Cocaethylene
☐ Muscle Relaxants:
 Carisoprodol
 Meprobamate
City/State/Zip: ____________________________________________________
Subscriber Name: _________________________________________________
Ordering Physician: _______________________________________________
Ordering Physician NPI #: _________________________________________
Patient Medication List
☐ Heroin:
 6-acetylmorphine
☐ Hallucinogens:
 Phencyclidine (PCP)
http://pathlabs.ufl.edu
CLINICAL TOXICOLOGY REQUISITION
Patient Phone #: __________________________________________________
Drug Class Screen (immunoassay)
Can be ordered as a panel or individually
☐ Panel (includes these tests)
☐ Amphetamines
☐ Barbiturates
☐ Cannabinoids
☐ Cocaine
☐ Heroin
Specimen Validity*
☐ Specimen Validity Panel
 Creatinine
 pH
 Oxidants
 Specific gravity
:
Collection Date: ________________________Time: ___________
A.M./P.M.
*
Validity testing can help ensure that specimens have not been adulterated.
Revised
7/17/2014
UF Health Pathology Laboratories | 4800 SW 35 th Drive | Gainesville, FL 32608 | Toll-Free: 888.375.5227 (LABS) | Phone: 352.265.9900 | Fax: 352.265.9901