2700 NE Andresen Rd., Ste. E-3
Vancouver, WA. 98661
(p)360.693.8850
(f)360.694.7988
www.moleculartestinglabs.com
1. PATIENT INFORMATION
LAST NAME:
SEX:
Laboratory Use Only:
FIRST:
DOB:
PATIENT ADDRESS:
BARCODE
2. SPECIMEN INTAKE DETAILS
MI:
COLLECTOR’S NAME:
SSN:
DATE COLLECTED
TEMPERATURE READ WITHIN 4 MINUTES
AND IS IN RANGE OF 32.5-37.7 C (90.5-100 F)
PHONE:
3. PRACTICE INFORMATION:
REQUESTING PROVIDER:
DIAGNOSIS CODES:
□ 337.20
CLINIC ADDRESS:
TIME COLLECTED
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729.5
338.2
CLINIC PHONE:
□ YES
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□ __________
□ __________
338.29
V58.69
NO
REQUIRED: Attach patient face sheet, as well as front and back copies of current insurances card(s).
4. TEST ORDERED (descriptions on back)
□ 1001 Total Panel 1
□ 1002 Total Panel 2
□ 1003 Total Panel 3
□ 1501 Confirm all POC
□ 1504 Illicit Panel
□ 1502 Confirm all POC Positive Results □ 1505 Buprenorphine
□ 1503 Confirm Medication List
□ 1506 Benzodiazepines
□ 1510 Lab Panel A
□ __________________
□ __________________
The ordering physician or his/her authorized representative must sign his/her name and indicate the date the test is ordered. The signature constitutes a certification that,
with respect to tests reimbursed by Medicare or other third party payers, the testing is medically necessary and the results will be used in the management of the patient.
Physician Signature: _________________________________
5. CURRENT MEDICATIONS
□ NO DRUGS PRESCRIBED
□ Alprazolam (Xanax)
□ Amphetamine (Benzedrine)
□ Buprenorphine (Buprenex)
□ Carisoprodol (Soma)
□ Chlordiazepoxide (Librium)
□ Clonazepam (Klonopin)
□ Codeine (Tylenol 2,3,4)
□ Diazepam (Valium)
□ Fentanyl (Atiq, Duragesic)
□ Flunitrazepam (Rohypnol)
□ Others: _______________
□ Others: _______________
7. AUTHORIZATION
□ Flurazepam (Dalmane)
□ Hydrocodone (Norco, Vicodin)
□ Hydromorphone (Dilaudid)
□ Lorazepam (Ativan)
□ Meprobamate (Miltown)
□ Merperidine (Demerol)
□ Methadone (Dolophine)
□ Methamphetamine (Methedrine)
□ Midazolam (Versed)
□ Morphine (MS Contin)
□ Naloxone (Narcan)
□ Others: _________________
□ Others: _________________
Date : _________________________________
□ Naltrexone (Revia)
□ Oxazepam (Serax)
□ Oxycodone (Oxycontin, Percocet)
□ Propoxyphene (Darvocet)
□ Sufentanil (Sufenta)
□ Temazepam (Restoril)
□ Tramadol (Ultram)
□ Others: ___________________
□ Others: ___________________
□ Others: ___________________
□ Others: ___________________
□ Others: ___________________
□ Others: ___________________
6. POINT OF CARE RESULTS
Confirm
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TESTS
POS / NEG
Amphetamine
Barbiturates
Benzodiazepines
Cocaine
Ecstasy
Marijuana
Methamphetamine
Methadone
Opiates / Morphine
Oxycodone
Phencyclidine
Tricyclic Antidepressants
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I certify that I have voluntarily provided a fresh, unadulterated urine specimen for analytical testing. The information provided on this form and on the label affixed to the
specimen bottle is accurate. I authorize Molecular Testing Labs to: 1) release the results of this testing to the ordering provider, 2) bill and collect payment from my
health insurance 3) bill me for any covered service deductible, copayment and/or coinsurance 4) obtain any information necessary from the ordering provider in an
attempt to obtain payment from my insurance. I understand that Molecular Testing Labs may be out-of-network with my health insurance company and if payment is
remitted directly to me I am responsible to Molecular Testing Labs for the amount tendered.
Patient Signature: ________________________________________
White – Lab Copy (Must accompany specimen)
Canary – Patient Copy
Date: _______________
Pink – Provider Copy
Test Menu
All positive screens trigger confirmation testing. Confirmation for all parent drugs will include associated metabolite(s).
1001 Total Panel 1
5001 6-Acetylmorphine (6-AM)
5002 alpha-hydroxyalprazolam
5003 Alprazolam
5006 Amphetamine
5007 Benzoylecgonine
5008 Buprenorphine
5013 Carisoprodol
5015 Clonazepam
5016 Codeine
5018 Diazepam
5020 EDDP (perchlorate)
5022 Fentanyl
5023 Flunitrazepam
5025 Flurazepam
5026 Hydrocodone
5027 Hydromorphone
5030 Lorazepam
1002 Total Panel 2
1003 Total Panel 3
5001 6-Acetylmorphine (6-AM)
5006 Amphetamine
5001 6-Acetylmorphine (6-AM)
5006 Amphetamine
1501 Confirm all POC
Confirm and Quantitate
1505 Buprenorphine
5008 Buprenorphine
all test results on
5046 Norbuprenorphine
1506 Benzodiazepine
5008 Buprenorphine
1506 Benzodiazepine
5008 Buprenorphine
Provider POC cup
6000 Specimen Validity
5013 Carisoprodol
5007 Benzoylecgonine
5013 Carisoprodol
5007 Benzoylecgonine
1502 Confirm all POC Positive
5022 Fentanyl
5034 MDMA
5022 Fentanyl
5034 MDMA
Confirm and Quantitate
Nordiazepam
all Provider reported
Diazepam
5035 Meperidine
5038 Methadone
5035 Meperidine
5038 Methadone
Positive Results from
Oxazepam
POC cup
Tamezapam
5053 Oxycodone
5058 Phencyclidine
5053 Oxycodone
5058 Phencyclidine
6000 Specimen Validity
5061 Propoxyphene
5066 THC-COOH
5061 Propoxyphene
5068 Tramadol
1503 Confirm Medication List
5068 Tramadol
6000 Specimen Validity
1506 Benzodiazepines
Clonazepam
Lorazepam
Flurazepam
Midazolam
Alprazolam
Confirm and Quantitate
all reported medications
6000 Specimen Validity
1510 Lab Panel A
Screen for all analytes not
5032 MDA
5033 MDEA
5034 MDMA (ecstasy)
5035 Meperidine
5037 Meprobamate
5038 Methadone
1504 Illicit Panel
5001 6-Acetylmorphine (6-MAM)
tested on referring lab
5007 Benzoylecgonine
5032 MDA
positives and required
5033 MDEA
5034 MDMA (ecstasy)
confirmed and quantitated
5058 Phencyclidine (PCP)
6000 Specimen Validity
5039 Methamphetamine
5040 Midazolam
report. All reported
medications will be
6000 Specimen Validity
6001 Creatinine
6002 pH
5041 Morphine
5043 Naloxone
6003 Specific Gravity
6004 Nitrite
5044 Naltrexone
5046 Norbuprenorphine
5047 Nordiazepam
5048 Norfentanyl
5049 Normeperidine
5050 Norpropoxyphene
5052 Oxazepam
5053 Oxycodone
5054 Oxymorphone
5058 Phencyclidine (PCP)
5061 Propoxyphene
5064 Sufentanil
5065 Temazepam
5068 Tramadol
6000 Specimen Validity
Individual Test Menu
All testing performed using LC/MS technology
5001 6-Acetylmorphine (6-MAM)
5002 alpha-hydroxyalprazolam
5018 Diazepam
5020 EDDP (perchlorate)
5032 MDA
5033 MDEA
5041 Morphine
5043 Naloxone
5052 Oxazepam
5053 Oxycodone
5003 Alprazolam(xanax)
5006 Amphetamine
5022 Fentanyl
5023 Flunitrazepam
5034 MDMA (ecstasy)
5035 Meperidine
5044 Naltrexone
5046 Norbuprenorphine
5054 Oxymorphone
5058 Phencyclidine (PCP)
5007 Benzoylecgonine
5008 Buprenorphine
5025 Flurazepam
5026 Hydrocodone
5037 Meprobamate
5038 Methadone
5047 Nordiazepam
5048 Norfentanyl
5061 Propoxyphene
5064 Sufentanil
5013 Carisoprodol
5015 Clonazepam
5027 Hydromorphone
5030 Lorazepam
5039 Methamphetamine
5040 Midazolam
5049 Normeperidine
5050 Norpropoxyphene
5065 Temazepam
5068 Tramadol
5016 Codeine