8445 S Eastern Ave
Las Vegas, NV 89123
P: 702-463-3784
F: 702-463-3236
www.grihealth.com
Requesting Provider :
123456
Address:
CHAIN OF CUSTODY FORM
Lab Dir: Beata J Kwialkowska,MD
CLIA: 29D2093280
NPI
1. DEMOGRAPHICS
Pt. Last Name:* _____________________ First Name:* ________________________
Insurance Co: _______________________ Policy #: ___________________________
Work Comp DOI: ___/___/________
Client Bill
Medicare
Self-Pay
HMO
Multiplan
PPO
ICD-10 Diagnosis Code(s):
SSN #: ________ - ______ - __________ DOB (mm/dd/yyyy):* _____/____/________
Medicaid
2. You Must Attach a Copy of the Front and Back of the Patient's Insurance Card and Demographics*
Consent to Testing and Use of Results: The specimen identified on this
form is my own. I have not adulterated it in any way. I am voluntarily
submitting this specimen for analysis by my provider, Global Research
Institute (GRI). I authorize GRI to release the test results to the ordering
provider.
Financial/Insurance Authorization: I assign my insurance benefits (if any) and authorize any insurance payments to be paid to Global Research
Institute for the laboratory services ordered herein by my practitioner. I authorize my practitioner and insurance company (if any) to release to
Global Research Institute and its agents any information needed to determine insurance benefits for laboratory services ordered herein. I consent
to Global Research Institute appealing on my behalf any denial of payment by my insurance company (if any) for the laboratory services ordered
herein, and further consent to the release by Global Research Institute, my practitioner, or my insurance company (if any) of any medical records or
other information necessary for insurance claims processing and any appeal. If I am a self-pay/cash patient, then I accept full responsibility for all
charges associated with this testing.
PATIENT SIGNATURE:* _____________________________
DATE: ______________________
Collector’s Name: ______________________ Sample Type: ________________
Date:* _______________
Temp: __________ Time: __________
3. Point-of-Care Test Results
Pos Neg
Pos Neg
Pos Neg
Pos Neg
Pos Neg
AMP
COC
MTD
PCP
BUP
BAR
mAMP (MET)
OPI
TCA
PPX
BZO
MDMA
OXY
THC
Drug Presumptive (16-drug) + Spec Validity by EIA
Benzodiazepines, Barbiturates, Cocaine, Marijuana,
Methamphetamine, Opiates, Methadone, Oxycodone,
Ecstasy (MDMA), PCP, Amphetamine, Proproxyphene,
Oxidants, Creatinine, pH, Specific Gravity, Temp
Drug Presumptive (23-drug) by EIA
16-drug + Nicotine, Carisoprodol, K2, ETG, EDDP,
Fentanyl, Heroin, Buprenorphine, Alcohol, Tramadol
4. Check Box/Boxes for Test Requests:
LCMSMS 17-drug analysis
Prescription Drugs
Confirm RX
Prescription Drugs
LCMSMS 47-drug analysis
Confirm RX
Prescription Drugs
LCMSMS 64-drug (complete) analysis
Confirm RX
Prescription Drugs
Confirm RX
Prescription Drugs
Amphetamines (47)
Diazepam
Codeine
Amphetamine
Flunitrazepam
EDDP
MDA
Flurazepam
Fentanyl
Others (17)
Cyclobenzaprine
MDMA
Lorazepam
Hydrocodone
Carisoprodol
Nortriptyline
Methamphetamine
Midazolam
Hydromorphone
Ethyl Glucuronide (EtG)
Phentermine
Oxazepam
Meperidine
Ethyl Sulfate (EtS)
Temazepam
Methadone
Gabapentin
Barbiturates (47)
Morphine
Meprobamate
Butalbital
Norbuprenorphine
Naloxone
Propoxyphene
Illicits (47)
Norfentanyl
Naltrexone
Phenobarbital
Benzoylecogonine
Norhydrocodone
Pregabalin
Secobarbital
Cocaine
Normeperidine
Ritalinic Acid
PCP
o-desmethyltramadol
Zolpidem
THC-COOH
Oxycodone
Zopiclone
Oxymorphone
Cotinine
7-amino-clonazepam
Alprazolam
Opiates (47)
Sufentanyl
Ketamine
a-OH-Alprazolam
6-MAM
Tapentadol
Methylphenidate
Clonazepam
Buprenorphine
Tramadol
5. Prescription Info & Custom Test Panel Options
TCA (17)
Amitriptyline
Pentobarbital
Benzodiazepines (47)
Confirm RX
Pharmacogemonics
Comprehensive
Psych
Cardio
Pain
6. PROVIDER SIGNATURE
________________________________________________________________________________________________________
Documentation to support medical necessity for all tests ordered should be recorded in the patient’s chart. The provider signature is
required.
Medication List attached
Patient Name:
Date of Collection:
Patient Initials:
Patient reports “No Medications”
Notice to Ordering Provider: Provider must order only those tests that are medically necessary for the patient, given his or her clinical
condition. Provider must submit the diagnosis information for all tests ordered, and medical necessity should be documented in the
patient’s medical record. Medicare, Medicaid, and other third-party payers will only pay for tests that meet the payer’s coverage
criteria and are reasonable and necessary to treat or diagnose the patient. I understand that if I order medically unnecessary tests that
are billed to Medicare, Medicaid, or other government payers.
DOB:
Time of Collection:
Collector’s Initials: ________________________
123456