welcome manual - Castle Medical

WELCOME MANUAL
molecular diagnostics | toxicology services
CEO
A WELCOME MESSAGE FROM OUR
Welcome to the Castle Family! I would first like to take a moment to personally thank you for choosing
Castle Medical as your wellness partner. We promise to do everything in our power to make sure that
this is the best decision you have ever made.
As a world-class healthcare organization we provide exceptional service and strive to deliver a superior
quality of care. Although we understand that anyone can say this, the reality is that we back it up. Since
our inception in 2004, our goal and vision has never waned; to bring truth and common sense to
healthcare. While we are closer to realizing this goal more than we were yesterday, there is still a long
way to go to bring about real change to the healthcare industry.
Castle Medical was founded on the belief that if you follow a positive pattern of behavior, your results
will always be consistent with your output. With this in mind, we implore all of our employees to follow
our canons; be authentic, be creative, be accountable, be fun, be thankful, be of service, take action,
be tenacious. If you ever feel that any of our employees are not acting with one of these in mind, please
let us know and we will take action immediately.
We aspire to be the most innovative, customer-centric, moving at the speed-of-light organization, while
never losing sight of our origins. Our team is aligned to inspire real change and we are extremely excited
that you will be a part of our vision to overhaul the healthcare system, one happy patient at a time.
Finally, it is no secret that we are an award winning company with an award winning attitude. Most
recently we were honored by Inc. Magazine as the #1 Fastest Growing Healthcare Organization on
their annual Inc. 5000 list. We have also been recognized by The Atlanta Journal-Constitution as Atlanta’s
Top Workplaces, as well as received other prestigious awards for which we are both honored and proud
to have hanging on our walls.
What this tells us is that while our employees love working for us, just as importantly, our customers love
working with us.
Warmest regards,
Scott M. Damron
1
CASTLE MEDICAL
Corporate Contact Information
, LLC
Main Number:
678-486-7340
Toll Free:
855-8CASTLE
Fax Number:
678-486-7350
Toll Free:
855-9CASTLE
Laboratory - [email protected]
Chief Toxicologist
Thomas David
Lead Toxicologist (Urine)
(227853)
(227853)
DEPARTMENTS
678-486-7340 ext 604
[email protected]
Yan Zou, Ph.D.
678-486-7340 ext 611
[email protected]
Lead Toxicologist (Blood/Saliva)
Rahul Nahire, Ph.D.
678-486-7340 ext 618
[email protected]
Lead Geneticist (DNA)
Alex Schmidt
678-486-7340 ext 641
[email protected]
Molecular Biologist
Varsha Meghnani, Ph.D.
678-486-7340 ext 657
[email protected]
General Counsel:
Scott Damron
678-486-7340 ext 606
[email protected]
General Operations:
Jennifer Blair
678-486-7340 ext 603
[email protected]
Marketing & Design:
Daniel Battaglia
678-486-7340 ext 621
[email protected]
Client Billing:
Gina Stieber
Sue Mayberry
Lucy Perkins
678-486-7340 ext 627
678-486-7340 ext 632
678-486-7340 ext 609
[email protected]
[email protected]
[email protected]
Analyzer:
Charles Minando
678-486-7340 ext 610
[email protected]
IT Support:
Alisa Bucy
678-486-7340 ext 631
[email protected]
Management & Operations
Client Service Representative by State:
Saeeda Bah
678-486-7340 ext 644
[email protected]
Isaiah Wilson
678-486-7340 ext 612
[email protected]
Rose Butt
AR, IA, IL, IN, KS, LA, MI, MN, MO, MS, NE, OH, OK
678-486-7340 ext 634
[email protected]
Kathryn Brown
678-486-7340 ext 626
[email protected]
AL, CT, DE, DC, KY, MA, ME, MD, NC, NH, NJ, NY, PA, RI, TN, VA, VT, WV
FL, GA, SC
AZ, CA, CO, ID, MT, ND, NM, NV, OR, SD, TX, UT, WA, WI, WY
2
OUR COMPREHENSIVE SERVICES
Toxicology Services
Departments Include: 1. Pain Management 2. Work-Place Drug Testing 3. Forensic Toxicology 4. Therapeutic Drug Monitoring
Castle Medical has committed itself to fully serve the pain management specialty area with state-of-the art toxicology labs
headquartered in Atlanta, Georgia. While our focus is on drugs of abuse testing, our duty is to physicians and their
patients, and although we have put together the industry’s most comprehensive and functional testing panels, we offer a
plethora of toxicology testing services from which physicians may choose in order to tailor programs to their patients’
specific needs. With expert staffing and premium toxicology services, our scientific testing laboratories provide fast and
accurate results for submitted specimens.
Departments Include: 1. Pharmacogenetics 2. Genetics 3. Oncology 4. Infectious Diseases
Molecular Diagnostics
CORE DME: (Pharmacogenetics)
Our Core DME panel tests for genes affecting the metabolism of several classes of drugs. The tested genes include: CYP2D6, CYP2C9,
CYP2C19, CYP2B6, CYP3A4, and CYP3A5. In addition to this, other genes like OPRM1, SLCO1B1 and COMT which contribute to
drug response and clearance are also tested in this panel.This panel will provide prescribers critical information regarding a patient’s
metabolic phenotype. The metabolic rate of an individual in terms of TCAs, opiates, oncological, cardiovascular, and psychotropic drugs
may be ascertained and the most effective dosage may be prescribed for optimal therapeutic use.
Chemo DME: (Pharmacogenetics)
This panel tests for the TPMT, DPYD, and UGT1A1 genes. These genes are responsible for the body’s metabolism of several commonly
prescribed chemotherapeutic drugs. Utilizing this panel will enhance a physician’s ability to predict adverse side effects that range from
diarrhea to organ failure and facilitate the optimal, targeted personalized therapy for oncological purposes.
Warfarin: (Pharmacogenetics)
This panel is designed exclusively to test for genes associated with warfarin, also known as Coumadin, response. The genes included are
VKORC1, GGCX, CYP4F2, and CACNA1C. The results can help assess the best dosage for a patient in order to prevent severe risk and
side effects to the patient. This provides physicians with the means to provide targeted therapy based on individualized, genetic
information.
MTHFR and Homocysteinemia: (Genetics)
MTHFR gene encodes for methylenetetrahydrofolate reductase enzyme that plays a critical role in vitamin-B, folate and homocysteine (a
potentially toxic amino acid) metabolism. Genetic variations in the MTHFR gene can cause the enzyme to work less efficiently and can
lead to elevated homocysteine levels. Enhanced plasma homocysteine has been identified as a risk factor for occlusive disease in the
coronary, cerebral and peripheral arteries and for venous thrombosis. It has also been related to the occurrence of neural tube defects
and other pregnancy complications. Such genetic variations are common - around 12% of Caucasians are affected by just one of the
many possible MTHFR variants. In addition to the MTHFR genetic test, we also offer a blood test to detect elevated homocysteine
levels as a confirmatory test for MTHFR functional deficiency.
BRCA Variant Testing: (Oncology) - Coming Soon
BRCA1 and BRCA2 are tumor suppressor genes, which means that they help repair DNA damage and destroy cells with irreparable
DNA before they can become cancerous. People with non-functional variants of BRCA1 or BRCA2 are at an increased risk of developing several types of cancer - especially breast and ovarian cancer. Knowledge of a patient’s BRCA1/2 status can help them make
preventative choices, as was the case with Angelina Jolie’s double mastectomy.
Durable Medical Equipment
Our Durable Medical Equipment (DME) company, Drawbridge Medical specializes in supporting pain
physicians with the industry’s best braces, pumps and other products to empower patients’ to live
again. With our no-hassle, all reward guarantee we’re confident patients will feel the difference.
Castle Billing Solutions
A billing solutions service that provides financial benefits to every physician.
3
BILLING
COMING SOON!
DRUGS WE TEST FOR
CURRENT TOTAL: 120+
THE COMPREHENSIVE PANEL
THE FOLLOWING IS AVAILABLE IN
4
DRUGS WE TEST FOR
CURRENT TOTAL: 120+
5
THE COMPREHENSIVE PANEL
THE FOLLOWING IS AVAILABLE IN
DRUGS WE TEST FOR
CURRENT TOTAL: 120+
THE COMPREHENSIVE PANEL
THE FOLLOWING IS AVAILABLE IN
6
DRUGS WE TEST FOR
CURRENT TOTAL: 120+
THE COMPREHENSIVE PANEL
THE FOLLOWING IS AVAILABLE IN
7
DRUGS WE TEST FOR
4-OH Phenytoin
6-MAM (Heroin)
6-β-Naltrexol
7-OH-Mitragynine
25I-NBOMe
Actiq (Fentanyl)
Adderall (Amphetamine)
Alpha PVP
Alprazolam (4-HydroxyAlprazolam)
Ambien (Zolpidem)
Amitriptyline
Amphetamine
Aricept (Donepezil)
Ativan (Lorazepam)
Avinza (Morphine)
Benzoylecgonine (Cocaine)
Buprenex (Buprenorphine)
Buprenorphine
Butalbital
Carisoprodol
Chlordiazepoxide (Librium)
Clonazepam (7-AminoClonazepam)
Cocaine (Benzoylecgonine)
Codeine
Cognex (Tacrine)
Concerta (Methylphenidate)
Cotinine (Nicotine)
Cyclobenzaprine (Flexeril)
D-Methamphetamine
D-Amphetamine
Dalmane (HydroxyethylFlurazepam)
Darvocet (Propoxyphene)
Darvon (Propoxyphene)
Demerol (Meperidine)
Desoxyn (Methamphetamine)
Dexedrine (Amphetamine)
Diazepam
Dilaudid (Hydromorphone)
Dilantin (Phenytoin)
Dihydrocodeine (Trezix)
Dolophine (Methadone)
Donepezil (Aricept)
Duragesic (Fentanyl)
Duramorph (Morphine)
Ecstasy (MDMA)
Elavil (Amitriptyline)
Endocet (Oxycodone)
Ethyl Glucuronide
Ethyl Sulfate
Exalgo (Hydromorphone)
Exelon (Rivastigmine)
Fentanyl
Fentora (Fentanyl)
Fioricet (Butalbital)
Fiorinal (Butalbital)
Flexeril (Cyclobenzaprine)
Flurazepam (HydroxyethyFlurazepam)
Gabapentin (Neurontin)
Halcion (Triazolam)
Heroin (6-MAM)
A-Z
Hydrocet (Hydrocodone)
Hydrocodone
Hydromorphone
Hydrostat IR (Hydromorphone)
HydroxyethyFlurazepam (Flurazepam)
JWH-018 -Synthetic Cannabinoids
(K2/Spice)
JWH-073-Synthetic Cannabinoids
(K2/Spice)
Kadian (Morphine)
Klonopin (Clonazepam)
Kratom (Mitragynine)
L-Methamphetamine
L-Amphetamine
Librium (Chlordiazepoxide)
Lacosamide
Lorazepam
Lorcet (Hydrocodone)
Lortab (Hydrocodone)
Lunesta (Zopiclone/Eszopiclone)
Lyrica (Pregabalin)
Marijuana (THCA)
Maxidone (Hydrocodone)
MDMA (Ecstasy)
MDPV (Methylenedioxypyrovalerone)
Memantine (Namenda)
Meperidine
Meprobamate (Miltown)
Methadone
Methadose (Methadone)
Methamphetamine (Desoxyn)
Methylone
Methylone-Cathinones
Methylphenidate
Midazolam (Versed)
Miltown (Meprobamate)
Mitragynine (Kratom)
Morphine
MMC (Mephedrone)
MS Contin (Morphine)
MSIR (Morphine)
Naloxone
Namenda (Memantine)
Neurontin (Gabapentin)
Nicotine
Norco (Hydrocodone)
Norcodeine
Norhydrocodone
Normorphine
Noroxycodone
Nordiazepam
Nortriptyline
Nucynta (Tapentadol)
Numorphan (Oxymorphone)
Opana (Oxymorphone)
Oramorph (Morphine)
Oxazepam
Oxy IR (Oxycodone)
Oxycodone
Oxycontin (Oxycodone)
Oxymorphone
PCP
Percocet (Oxycodone)
Percodan (Oxycodone)
Percolone (Oxycodone)
Phenobarbital
Phenytoin (Dilantin)
Pregabalin (Lyrica)
Propoxyphene
Quetiapine (Seroquel)
Ranitidine (Zantac)
Reprexain (Hydrocodone)
Restoril (Temazepam)
Ritalin (Methylphenidate)
Rivastigmine (Exelon)
Rohypnol (Flunitrazepam)
Roxanol (Morphine)
Roxicodone (Oxycodone)
Serax (Oxazepam)
Seroquel (Quetiapine)
Sertraline (Zoloft)
Soma (Carisoprodol)
Sonata (Zaleplon)
Suboxone (Buprenorphine/ Naloxone)
Subutex (Buprenorphine)
Tacrine (Cognex)
Tapentadol (Nucynta)
Temazepam
THCA (Marijuana)
Tramadol
Trezix (Dihydrocodeine)
Triazolam (Halcion)
Tussionex (Hydrocodone)
Tylenol #3 (Codeine)
Tylenol #4 (Codeine)
Ultracet (Tramadol)
Ultram (Tramadol)
Valium (Diazepam)
Versed (Midazolam)
Vicodin (Hydrocodone)
Vicoprofen (Hydrocodone)
Xanax (4-HydroxyAlprazolam)
Zaleplon (Sonata)
Zantac (Ranitidine)
Zohydro (Hydrocodone)
Zoloft (Sertraline)
Zolpidem (Ambien)
Zolpidem Phenyl COOH
Zonisamide
Zopiclone/Eszopiclone (Lunesta)
A-Z
NOTE: Our testing capabilities
are always expanding. Please
check with your representative
if a specific drug is not listed here
as it may have recently been added
to our list of drugs.
8
NEW REQUISITION FORM
N649601
N649601
PLACE OVER CAP
OF SPECIMEN
DATE:
___________
COLLECTOR INITIALS:
___________
TIME:
___________
PATIENT INITIALS:
___________
1
2
CASTLE MEDICAL, LLC
5700 Highlands Parkway, Suite 100
Smyrna, Georgia 30082
phone: 678-486-7340 toll free: 855-822-7853
fax: 678-486-7350 toll free: 855-922-7853
email: labsupport @ c a s t l e m e d i c a l . c o m
REQUESTING PHYSICIAN
6
PATIENT INFORMATION
MEDICAL NECESSITY : ICD-9 DIAGNOSIS CODES
Last: ______________________________ First: ________________________________ MI: ______
S. S. # : __________________________ D.O.B. ______ /______ /________
SEX:
M
F
Address: _________________________________________________________ See Attached
City: ____________________________ State: _____________ Zip Code: ___________________
Phone: (____) ________ - ___________ Email: _________________________________________
____
The information I have provided on this form is accurate. I authorize Castle Medical to release the results of this testing to the treating
physician or facility. I hereby authorize my insurance or other payment benefits to be paid directly to Castle Medical for services I received. I
acknowledge that Castle Medical may be an out-of-network provider with my insurer. I am also aware that in some circumstances my insurer might
send the payment directly to me. I agree to endorse the insurance check and forward to Castle Medical within fifteen days of receipt. I
acknowledge that I am responsible for all co-pays and deductibles not covered by insurance or other payors.
Patient Signature: ____________________________________ Date: _________________
_
3
PRIMARY INSURANCE INFORMATION
a
8
SELF PAY:
9
723.1
729.1
V58.69
OTHER
OTHER
OTHER
Physician Signature: ________________________________ Date: ____ /____ /______
I hereby authorize the laboratory tests selected below and acknowledge that the test(s) ordered are
medically necessary.
7
SPECIMEN SOURCE
D&L ISOMERS
BATH SALTS (urine only)
BUPRENORPHINE
COCAINE
_____________________________
ETG / ETS (Alcohol Metabolite) (urine only)
_____________________________
MARIJUANA
_____________________________
METHADONE
No Drugs Prescribed
See Attached
MUSCLE RELAXANTS
POINT-OF-CARE RESULTS
POS (+)
NICOTINE (urine only)
5
OXYCODONE
BARBITURATES (BAR)
PHENCYCLIDINE
BENZODIAZEPINES (BZO)
PROPOXYPHENE
BUPRENORPHINE (BUP)
SYNTH. CANNABINOIDS
COCAINE (COC)
TRICYCLICS
Z-DRUGS
ECSTACY (MDMA)
MARIJUANA (THCA)
c
8
PROPOXYPHENE (PPX) (PXP)
TRICYCLIC ANTIDEPRESSANTS (TCA)
Temperature must be read within 4
minutes and fall between the range
of 32.5 - 37.7 ºC (90.5 - 98.8 ºF).
Results outside range check this box.
SALIVA
x
x
x
(K2 | SPICE)
(urine only)
x
x
MODERATE
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
LOW
x
CUSTOM
x
x
x
x
x
x
x
x
x
x
x
PRE-CUSTOMIZED PANELS
OPIATES (OPI) (MOP)
PHENCYCLIDINE (PCP)
BLOOD
b
8
METHADONE (MTD)(MAD)
OXYCODONE (OXY)
x
x
x
x
x
x
x
OPIATES
-
NEG ( )
AMPHETAMINE (AMP)
HIGH
x
x
x
BENZODIAZEPINES
_____________________________
URINE
REQUESTED TEST(S) : QUANTITATIVE CONFIRMATION OF DRUGS BY LC/MS/MS
BARBITURATES
CURRENT MEDICATIONS : SHADE ALL THAT APPLY
Methylphenidate
Morphine
MS-Contin
MSIR
Neurontin
Norco
Norephedrine
Nortriptyline
Nucynta
Opana
Oxazepam
Oxycodone
OxyContin
Oxy IR
Oxymorphone
Percocet
Phenobarbital
Phentermine
Plegine
Pregabalin
PPA
Restoril
Ritalin
Roxicodone
Serax
Sertraline
Soma
Sonata
Suboxone
Subutex
Sudafed
Tapentadol
Temazepam
Tramadol
Tylenol #3, #4
Ultram
Valium
Vicodin
Vicoprofen
Vick’s Inhaler
Xanax
Zolpidem
719.41
ANTIEPILEPTICS
Member ID # : __________________________ Group ID #: _____________________
Adderall
Adipex
Alprazolam
Ambien
Amitriptyline
Ativan
Buprenorphine
Butalbital
Carisoprodol
Clonazepam
Codeine
Cyclobenzaprine
Dalmane
Demerol
Desipramine
Desoxyn
Dexedrine
Diazepam
Didrex
Dilaudid
Dolophine
Duragesic
Elavil
Endocet
Ephedrine
Fentanyl
Flexeril
Fioricet
Flunitrazepam
Flurazepam
Gabapentin
Hydrocodone
Hydromorphone
Imipramine
Kadian
Klonopin
Lorazepam
Lortab
Lunesta
Lyrica
Meperidine
Methadone
724.5
Medical necessity is defined as accepted health care services and supplies provided
by health care entities, appropriate to the evaluation and treatment of a disease,
condition, illness or injury and consistent with the applicable standard of care.
AMPHETAMINES
CLIENT BILL:
Insurance Company Name: ____________________________ See Attached
4
724.4
Check One: COMPREHENSIVE PANEL
REQUIRED: ENCLOSE A COPY OF THE FRONT & BACK OF PATIENT’S INSURANCE CARD(S)
INSURANCE:
724.2
_____________________________________________
____________________________________________
_____________________________________________
____________________________________________
REQUESTED TEST(S) NOT LISTED
_____________________________________________
____________________________________________
_____________________________________________
____________________________________________
d
8
ADDITIONAL TESTING OPTIONS
White - Castle Copy
Yellow - Physician Copy
URINE SCREENING
Pink - Patient Copy
URINE VALIDITY
V1.0
NEW REQUISITION FORM CHEAT SHEET
N649601
CASTLE MEDICAL, LLC
5700 Highlands Parkway, Suite 100
Smyrna, Georgia 30082
___________
___________
STEP 2.1 PEEL STICKER. PLACE
OVER CONTAINER
PLACE OVER
Make
sure to have Patient Initial and then Sign under Patient Signature
N
649601
CAP OF CUP
___________
___________
DATE:
COLLECTOR INITIALS:
phone: 678-486-7340 toll free: 855-822-7853
fax: 678-486-7350 toll free: 855-922-7853
email: labsupport@ c a s t l e m e d i c a l . c o m
PATIENT INITIALS:
(See STEP 2) at the same time. Peel sticker and place over specimen.
TIME:
1
REQUESTING PHYSICIAN
STEP 1. REQUESTING PHYSICIAN
Relates to patient/test
Please check the appropriate name(s) of the physician(s)
requesting the test(s).
Relates to physician/order
LabForms 888-200-5114
2
6
REQUIRED: ENCLOSE A COPY OF THE FRONT & BACK OF PATIENT’S INSURANCE CARD(S)
MEDICAL NECCESITY - ICD DIAGNOSIS CODES
STEP
PATIENT INFORMATION (ITEMS IN RED ARE REQUIRED)
PATIENT 2.
INFORMATION
STEP 6. ICD-9 DIAGNOSIS CODES
Last: __________________________
First:
_________________________
Middle
A. Last Name
B.
First
Name C. Social Security
# Initial: _______
In order to prove medical necessity the physician
729.1
V58.69
OTHER
OTHER
must provide a reason for why the test is being
performed.
S. S. # : __________________________
D. Date of Birth E.D.O.B.
Sex ______/______/________
SEX:
M
724.2
F
Address: _________________________________________________________ See Attached
Physician Signature: _______________________________ Date: ___ /____ /______
G. Phone & Email Address
H. Patient Signature & Date (See STEP 2.1 ABOVE)
Patient Signature: ___________________________________________ Date: _________________________
appropriate specimen source (Urine, Blood or Saliva).
PANEL
HIGH TEST(S)
MODERATE
STEPCOMPREHENSIVE
8a. REQUESTED
AMPHETAMINES
x
x
BARBITURATES
x
x
BENZODIAZEPINES
x
x
LOW
x
CUSTOM
x
D&L ISOMERS
If a quantitative
confirmation test is being requested we have a
x
x
ANTIEPILEPTICS
few
options for the physician to choose from:
Member ID # : __________________________ Group ID #: _____________________
CURRENT MEDICATIONS
STEP
Actiq 4. CURRENT
Lorazepam MEDICATIONS
Temazepam
Vicodin
Lorcet
Adderall
Tramadol
Vicoprofen
Lortab
Adipex
Tylenol #3
Vick’s Inhaler
Please
shade
in
(be
sure
to
fill
entire
bubble
provided)
Lunesta
Xanax
Alprazolam
Tylenol #4
Lyrica
________________
Ambien
Ultracet
ALL
MEDICATIONS currently prescribed
to patient. If _a___specific
Maxidone
____________________
Amitriptyline
Ultram
medication
is not available
please checkValium
blank boxes and
Meperidine
____________________
Ativan
Avinza medication. Methadone
write-in
No Drugs Prescribed
Methylphenidate
Buprenex
Morphine
See Attached
Buprenorphine
MS-Contin
Butalbital
If No
Prescriptions have
been
5
MSIR
Carisoprodol
POINT-OF-CARE RESULTS
prescribed
please check
the
Neurontin
Clonazepam
POS (+) NEG (-)
Norco
Codeine
“NO
DRUGS PRESCRIBED”
AMPHETAMINE (AMP)
Norephedrine
Cyclobenzaprine
box.
Nortriptyline
Dalmane
BARBITURATES (BAR)
Nucynta
Darvon
BENZODIAZEPINES (BZO)
Numorphan
Demerol
If you
have obtainedOpana
a copy of the Please check the results of
Desipramine
ALL
TESTED
DRUGS from
BUPRENORPHINE
(BUP)
DesoxynMedicationOramorph
patient’s
List, you can
Oxazepam
Dexedrine
the
Point-of-Care
cup test.
attach
it
to
the
requisition
form
COCAINE (COC)
Oxycodone
Diazepam
OxyContin
Dilaudid
and
select “SEE ATTACHED.”
ECSTACY (MDMA)
Oxy IR
Dolophine
Oxymorphone
Duragesic
MARIJUANA (THCA)
Percocet
Duramorph
EXAMPLES:
Percodan
Elavil
METHADONE (MTD)(MAD)
Percolone
Embeda
Adderall - ACCEPTABLE
Phenobarbital
Endocet
OPIATES (OPI)
Phentermine
Ephedrine
Adderall - NOT ACCEPTABLE
Pregabalin
Fentanyl
OXYCODONE (OXY)
Adderall - NOT ACCEPTABLE
TEMPERATURE
READING
PPA
Fentora
Restoril
Flexeril
Adderall - NOT ACCEPTABLE
IfPHENCYCLIDINE
sample is(PCP)
outside of range
Ritalin
Fioricet
please be sure to check the
Roxanol
Fiorinal
PROPOXYPHENE (PPX) (PXP)
Roxicodone
Flunitrazepam
box provided below.
Serax
Flurazepam
TRICYCLIC ANTIDEPRESSANTS (TCA)
Sertraline
Gabapentin
Soma
Hydrocodone
Temperature must be read within 4
Sonata
Hydromorphone
minutes and fall between the range
Suboxone
Hydrostat IR
of 32.5 - 37.7 ºC (90.5 - 98.8 ºF).
Subutex
Imipramine
Results outside range check this box.
Sudafed
Kadian
Tapentadol
Klonopin
a test please be
sure toBLOOD
check the SALIVA
STEP
7 Before
SPECIMEN SOURCE:
URINE
REQUESTED
TEST(S)selecting
URINE QUANTITATIVE CONFIRMATION OF DRUGS BY LC/MS/MS
INSURANCE:
SELF
CLIENT
BILL:
B. INSURANCE: Patient’s
insurance provider will
bePAY:
billed for services
rendered
C. SELF PAY: Patient will be billed directly by Castle Medical
Insurance Company Name: _____________________________________________
D. CLIENT BILL: Clinic will be billed directly by Castle Medical
WC/AUTO/LOP:
4
723.1
OTHER
I hereby
authorize
the laboratorydefault
tests selected
below and acknowledge
the test(s)
We
have
provided
common
codes,thatbut
theyordered are
medically necessary.
should only be selected if/when they match the
medical record for the patient.
The information I have provided on this form is accurate. I authorize Castle Medical to release the results of this testing to the treating
physician or facility. I hereby authorize my insurance or other payment benefits to be paid directly to Castle Medical for services I received. I
acknowledge that Castle Medical may be an out-of-network provider with my insurer. I am also aware that in some circumstances my insurer might
send the payment directly to me. I agree to endorse the insurance check and forward to Castle Medical within fifteen days of receipt. I
acknowledge that I am responsible for all co-pays and deductibles not covered by insurance or other payors.
7
719.41
medical record.
Phone: (____) ________ - ___________ Email: _________________________________________
____
3
724.5
Medical necessity is defined as accepted health care services and supplies provided
by health care entities, appropriate to the evaluation and treatment of a disease,
condition,
illness
or injury
and consistent
withprovided
the applicableinstandard
of care.
Please be
sure
to use
the code
the patient’s
F. Address: If you leave this area blank you must check “See
City: ____________________________ State: _____________ Zip Code: ___________________
Attached” and provide Demographic Documentation
PRIMARY
INSURANCE INFORMATION
STEP
3. INSURANCE
INFORMATION
724.4
Comprehensive
Panel: The comprehensive
panel is available for
x
BATH SALTS
the most common drugs ordered.
x
x
BUPRENORPHINE
High
Risk Patient: A full panel
of drugs
tested.x
x
COCAINE
x
Moderate Risk Patient: A less conservative comprehensive panel.
x
ETG / ETS (Alcohol Metabolite)
MARIJUANA
Low
Risk
STEP 5. POC
RESULTS
Patient: A
basicx
x
panel of commonly
prescribed drugs.
METHADONE
x
x
x
x
OPIATES
x
x
x
x
OXYCODONE
x
x
x
x
PHENCYCLIDINE
x
x
PROPOXYPHENE
x
x
x
x
Custom Panel: If the physician/clinic
would like to create (or has a
x
x
x
MUSCLE RELAXANTS
custom panel on file) please check the select which drugs are being
x
NICOTINE
requested
for the custom panel under the CUSTOM section.
x
SYNTH. CANNABINOIDS (K2 | SPICE)
8
TRICYCLIC ANTIDEPRESSANTS
x
x
Z-DRUGS
x
x
ADD TO PANEL
REQUESTED
TEST(S) NOT LISTED TEST(S)
STEP
8. ADDITIONAL
STAND-ALONE
_____________________________________________
____________________________________________
_____________________________________________
____________________________________________
8b: Pre-Customized Panels: Select from your customized panels.
ADDITIONAL
TESTING OPTIONS
8c: Requested
Tests Not
HORMONES
d
SCREENING
Listed: Order test(s)
not listed onVALIDITY
req. form.
/ Urine
Validity
8 : Urine Screening
EPITESTOSTERONE
PROGESTERONE
ALDOSTERONE
VITAMIN D
DHEA
DHEA-S
ESTRADIOL
ESTRIOL
FREE TESTOSTERONE
_____________________________________
White - Castle Copy
Yellow - Physician Copy
TSH
TOTAL TESTOSTERONE
T3
T4
FREE T3
_____________________________________
Pink - Patient Copy
V1.0
10
RECOMMENDED
PAIN MANAGEMENT CODES
Pain Management ICD-9 Codes
Backache NOS - 724.5
Brachial Neuritis NOS - 723.4
Carpal Tunnel Syndrome - 354
Cervicalgia - 723.1
Joint Pain – Lower Leg - 719.46
Spasm of Muscle - 728.85
Lumbar Disc Displacement - 722.10
Lumbosacral/Thoracic Neuritis NOS - 724.4
Lumbosacral Spondylosis - 721.3
Myalgia and Myositis NOS - 729.1
Pain in Limb - 729.5
Poslaminect Synd-Lumbar - 722.83
Lumb/Lumbosac Disc D - 722.52
Lumbago - 724.2
Spinal Stenosis-Limbar - 724.02
Therapeutic Drug Monitor - V58.83
The following ICD-9 codes (categories 303, 304 and 305) require
a fifth-digit sub-classification. The fifth-digits are as follows:
0 – unspecified 1 – continuous 2 – episodic 3 – in remission
Pain Management ICD-10 Codes
Additional descriptive codes available. Refer to your ICD-10 book for proper coding.
M54.89 - Other dorsalgia
M54.9 - Dorsalgia, unspecified
M54.12 - Radiculopathy, cervical region
M54.13 - Radiculopathy, cervicothoracic region
G56.00 - Carpal tunnel syndrome, unspecified upper limb
M54.2 - Cervicalgia
M25.569 - Pain in unspecified knee
M62.40 - Contracture of muscle, unspecified site
M62.838 - Other muscle spasm
M51.26 - Other intervertebral disc displacement, lumbar region
M51.27 - Other intervertebral disc displacement, lumbosacral region
M54.14 - Radiculopathy, thoracic region
M54.15 - Radiculopathy, thoracolumbar region
M54.16 - Radiculopathy, lumbar region
M54.17 - Radiculopathy, lumbosacral region
M47.817 - Spondylosis without myelopathy or radiculopathy, lumbosacral region
M60.9 - Myositis, unspecified
M79.1 - Myalgia
M79.7 - Fibromyalgia
M79.609 - Pain in unspecified limb
M96.1 - Postlaminectomy syndrome, not elsewhere classified
M51.36 - Other intervertebral disc degeneration, lumbar region
M51.37 - Other intervertebral disc degeneration, lumbosacral region
M54.5 - Low Back Pain
M48.06 - Spinal Stenosis, Lumbar Region
Z51.81 - Encounter for therapeutic drug level monitoring
RECOMMENDED
ABUSE DEPENDENCY CODES
Acute Alcohol Intoxication - 303.0
Other and Unspecified Alcohol Dependence - 303.9
Opioid Type Dependence - 304.0
Sedative, Hypnotic or Anxiolytic Dependence -304.1
Cocaine Dependence - 304.2
Amphetamine and other Psychostimulant Dependence - 304.4
Hallucinogen Dependence - 304.5
Other Specified Drug Dependence - 304.6
Combinations of Opioid Type Drug with any other drug dependence - 304.7
Combinations of Drug Dependence Excluding Opioid Type Drug - 304.8
Unspecified Dependence - 304.9
Alcohol Abuse - 305.0
Cannabis Abuse - 305.2
Hallucinogen Abuse - 305.3
Sedative, Hypnotic or Anxiolytic Abuse - 305.4
Opioid Abuse - 305.5
Cocaine Abuse -305.6
Amphetamine or Related Acting Sympathomimetic Abuse -305.7
Antidepressant Type Abuse - 305.8
Other Mixed or Unspecified Drug Abuse -305.9
11
F10.229 - Alcohol dependence with intoxication, unspecified
F10.20 - Alcohol dependence, uncomplicated
F10.21 - Alcohol dependence, in remission
F11.20 - Opioid dependence, uncomplicated
F11.21 - Opioid dependence, in remission
F13.20 - Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.21 - Sedative, hypnotic or anxiolytic dependence, in remission
F14.20 - Cocaine dependence, uncomplicated
F14.21 - Cocaine dependence, in remission
F15.20 - Other stimulant dependence, uncomplicated
F15.21 - Other stimulant dependence, in remission
F16.20 - Hallucinogen dependence, uncomplicated
F16.21 - Hallucinogen dependence, in remission
F19.20 - Other psychoactive substance dependence, uncomplicated
F19.21 - Other psychoactive substance dependence, in remission
F10.10 - Alcohol abuse, uncomplicated
F12.10 - Cannabis abuse, uncomplicated
F12.90 - Cannabis use, unspecified, uncomplicated
F16.10 - Hallucinogen abuse, uncomplicated
F13.10 - Sedative, hypnotic or anxiolytic abuse, uncomplicated
F11.10 - Opioid abuse, uncomplicated
F14.10 - Cocaine abuse, uncomplicated
F15.10 - Other stimulant abuse, uncomplicated
F19.10 - Other psychoactive substance abuse, uncomplicated
F18.10 - Inhalant abuse, uncomplicated
The above ICD-10 codes might require a 6th additional
character. Refer to your ICD-10 book for proper coding.
URINE SPECIMEN CUP
SAMPLE INSTRUCTIONS
1. Tighten the lid of the specimen container.
It will make a CLICK sound when tightened. Please
make sure there is at least 30 mL of urine in the
container. NOTE: Failure to obtain this minimum
requirement will result in a rejected sample.
2. Place a label from the requisition form over the top
of the container and secure to the sides of the cup.
This label serves to both identify the specimen and
prevent leakage. Make sure the label is marked
according to the requisition form instructions.
3. Place the sealed specimen container into the zippered
portion of the specimen bag and seal.
Fold the completed white copy of the Laboratory Requisition
and a copy of the patient’s insurance card (if applicable) along
with any other supporting documentation and place in the
outer pocket of the specimen bag.
4. Place an absorbent pad inside the large plastic
Clinical Pack.
Seperate the absorbent pad so that the specimen(s)
can be placed inside of the pad.
6. Contact FedEx (1-800-463-3339) to schedule a
pickup or contact Castle Medical directly at
(678) 486-7340 to schedule your pickup.
5. Package sealed specimen bags inside the large plastic
Clinical Pack from FedEx and seal.
Seal the Clinical Pack by removing the adhesive strip
and folding over. Place the Clinical Pack inside the
FedEx box and place the prepaid label on the outside
of the box by removing the backing portion of the label.
12
URINE TRANSPORT VIAL
SAMPLE INSTRUCTIONS
IMPORTANT INFORMATION
NO PEE LEFT BEHIND: You must always work with
one sample at a time to ensure that you do not mix
one patient’s sample with another patient’s information.
1
To open collection cup, tear shrink
banding along perforations, which
are marked with printed arrows.
5
9
13
Carefully transfer patient’s
urine using the beaker into vial.
Take completed copy of
requisition and add additional
documents (if necessary) and
insert into rear pocket.
2
Remove vials and bag from
collection cup.
6
Snap vial closed completely and
fold lid tab down to lock vial.
Make sure you hear a “CLICK.”
10
Remove release liner from bag
and seal.
3
7
Give collection cup to patient
and have them fill with urine.
NOTE: This cup may also be
used as a beaker.
Place security seal sticker
from patient’s requisition
form over top of vial.
4
Single Sample – Tear shrink
band along perforations.
8
Insert vial(s) into front
pocket of Specimen bag.
ORAL FLUID (SALIVA)
SAMPLE INSTRUCTIONS
A. Oral Fluid Collection Procedure
The QuantiSAL saliva Collection Device with Volume Adequacy Indicator is used for the oral fluid collection. Authorized personnel at the collection site should peel the pad package and remove the collector.
The collector is placed under the tongue with the mouth closed. The collector device should not be
moved during sampling for accurate and consistent absorption of the drugs present in saliva. When
indicator window turns blue, the collector is removed. The transport tube containing 3 mL of non-azide
preservative buffer is positioned upright and uncapped, and the collector is inserted into the transport
tube until it snaps firmly into place for transportation.
B. Fill out the requisition form appropriately and be sure to select “SALIVA” as specimen source.
C. Shipping and Handling Instructions
1. Tighten the lid of the specimen tube. It will make a “click” when it is tightened. Also, make sure
there is at least 5 mL of Blood in the tube for testing. For saliva samples ensure that the seal is tight
and firm.
2. Place a label from the requisition form over the top of the tube, and secure it to the sides. This label
serves to both identify the specimen and prevent leakage. Make sure the label is marked according to
the requisition form instructions.
3. Place the sealed specimen tube into the zippered portion of the specimen bag and seal. Fold the
completed white copy of the Laboratory Requisition and a copy of the patient’s insurance card, if
applicable, along with any other supporting documentation, and place it in the outer pocket of the
specimen bag.
4. Place an absorbent pad inside the large plastic Clinical Pack. Separate the absorbent pad so that
the specimens can be placed inside of the pad.
5. Package sealed specimen bags inside the large plastic Clinical Pack from FedEx and seal. Seal the
Clinical Pack by removing the adhesive strip and folding over.
6. Contact FedEx (1-800-463-3339) to schedule a pickup or contact Castle Medical directly at
(678) 486-7340 to schedule your pickup.
14
SAMPLE
RESULTS
CASTLE MEDICAL, LLC
5700 HIGHLANDS PKWY SUITE 100, SMYRNA, GA 30082-5142
PHONE: 678-486-7340 or 855-822-7853 FAX: 678-486-7350 or 855-922-7853
EMAIL: [email protected]
DIRECTOR: DR. JOHN D. ROBACK, MD., PH.D.
TECHNICAL SUPERVISOR: DR. JAMES RITCHIE, PH.D.
Client: CASTLE MEDICAL, LLC
Client #: 1
Chart #:
Doctor:
Patient: TESTER, FIRST
DOB: 01/01/1919
Gender: F
Specimen Type: URINE
Prescribed Medications:
Ambien (Zolpidem)
Percocet (Oxycodone)
CONFIRMATION RESULTS SUMMARY
Prescribed:
Zolpidem
Oxycodone
Oxymorphone
Not-Prescribed:
THCA
Buprenorphine
Norbuprenorphine
Ethyl Glucuronide
Ethyl Sulfate
Results in ng/ml
<RL
300
126
841
>2000
630
1540
1230
Lab Acc#: 1409122000
Collected: 09/11/14 03:00
Accessioned: 09/12/14 14:36
Reported on: 05/13/15 15:50 MSK
Reportable Limit (RL) in ng/ml
Interpretation
20
50
50
INCONSISTENT
CONSISTENT
CONSISTENT
15
5
10
250
250
INCONSISTENT
INCONSISTENT
INCONSISTENT
INCONSISTENT
INCONSISTENT
<RL: Less than reportable limit. The drug was either not detected or detected at levels too low to be accurately quantitated.
>: The drug was detected but at very high levels. Levels are too high to quantitate.
NT: Not Tested.
Remarks:
The presence of Norbuprenorphine is consistent with Buprenorphine medication.
THCA is a metabolite of THC (Marijuana).
EthylGlucuronide and EthylSulfate are metabolites of EthylAlcohol.
Comments:
-
Pregnancy test is performed by Qualitative detection of HCG in urine
SPECIMEN VALIDITY TESTING
TEST
RESULTS
Creatine
25.0
pH
5.6
Specific Gravity
1.0042
Nitrites
2
Oxidants/Bleach
250
FLAG
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
The results given are for clinical diagnostic purposes only.
15
EXPECTED RESULTS
>20 mg/dL
4.5 - 9.0
1.003 - 1.025
<7.5 mg/dL
<500 mcg/ml
IMMUNOASSAY SCREEN REPORT
DRUG
RESULTS
Oxycodone
POSITIVE
Methadone
NEGATIVE
Amphetamines
NEGATIVE
Opiates
NEGATIVE
Cocaine Metabolite
NEGATIVE
Benzodiazepines
NEGATIVE
THC
POSITIVE
Barbiturates
NEGATIVE
Pregnancy Test
NEGATIVE
CASTLE MEDICAL, LLC
(855)822-7853 Page 1
SAMPLE
RESULTS
Client: CASTLE MEDICAL, LLC
Client #: 1
Chart #:
Doctor:
Patient: TESTER, FIRST
DOB: 01/01/1919
Gender: F
Specimen Type: URINE
Lab Acc#: 1409122000
Collected: 09/11/14 03:00
Accessioned: 09/12/14 14:36
Reported on: 05/13/15 15:50 MSK
CONFIRMATION RESULTS USING LC/MS/MS
Drug Tested
Results
ng/ml
RL
AMPHETAMINES
Amphetamine
MDA
MDMA (Ecstasy)
Methamphetamine
Phenobarbital
<RL
<RL
<RL
<RL
200
100
100
200
<RL
<RL
200
200
BENZODIAZEPINES NEW
4-HydroxyAlprazolam
7-AminoClonazepam
Chlordiazepoxide
Diazepam
Flunitrazepam
HydroxyethylFlurazepam
Lorazepam
Midazolam
Nordiazepam
Oxazepam
Temazepam
Triazolam
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
20
20
20
20
20
20
20
20
20
20
20
20
OTHER ILLICITS
Benzoylecgonine (Cocaine)
PCP
THCA
Results
ng/ml
RL
OPIATES/OPIOIDS
BARBITURATES
Butalbital
Drug Tested
<RL
<RL
841
100
25
15
6-MAM
Buprenorphine
Carisoprodol
Codeine
DesmethylTapentadol
Dextromethorphan
Dextrorphan
Dihydrocodeine
EDDP
Fentanyl
Gabapentin
Hydrocodone
Hydromorphone
Meperidine
Meprobamate
Methadone
Morphine
Naloxone
Norbuprenorphine
Norfentanyl
Normeperidine
Norpropoxyphene
O-DesmethylTramadol
Oxycodone
Oxymorphone
Pregabalin
Propoxyphene
Tapentadol
Tramadol
The results given are for clinical diagnostic purposes only.
Drug Tested
Results
ng/ml
RL
ANTIDEPRESSANTS
<RL
>2000
4
5
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
<RL
100
50
50
50
50
50
50
100
50
50
20
<RL
4
10
<RL
<RL
<RL
300
126
<RL
Ritalinic Acid
<RL
Sertraline
Zopiclone/Eszopiclone
50
50
50
50
100
50
100
<RL
50
<RL
20
<RL
Zolpidem
20
<RL
20
<RL
50
BATH SALTS
MDPV
MEPHEDRONE
<RL
METHYLONE
<RL
Alpha-PVP
ALCOHOL
50
Ethyl Sulfate
50
<RL
Nortriptyline
50
100
<RL
Methylphenidate
Zaleplon
50
<RL
Imipramine
50
50
<RL
Desipramine
Z-DRUGS
300
<RL
Cyclobenzaprine
2
<RL
630
Amitriptyline
<RL
Ethyl Glucuronide
1540
1230
50
50
10
250
250
50
<RL
<RL
<RL
<RL
100
100
50
100
CASTLE MEDICAL, LLC
(855)822-7853 Page 2
16
DNA REQUISITION FORM
5700 Highlands Parkway, Suite 100
Smyrna, Georgia 30082
678-486-7340 or 855-822-7853
678-486-7350 or 855-922-7853
DNA@ castlemedical.com
D00001
Sex:
:
See Attached
The information I have provided on this form is accurate. I authorize Castle Medical to release the results of this
testing to the treating physician or facility. I hereby authorize my insurance or other payment benefits to be paid
directly to Castle Medical for services I received. I acknowledge that Castle Medical may be an out-of-network
provider with my insurer. I am also aware that in some circumstances my insurer might send the payment directly
to me. I agree to endorse the insurance check and forward to Castle Medical within fifteen days of receipt. I
acknowledge that I am responsible for all co-pays and deductibles not covered by insurance or other payors.
WC/Auto/LOP:
Insurance:
Client Bill:
Self Pay:
Specimen Source
Buccal Swab
______________
______________
D00001
Time: ___________
Collector Initials: ___________
Date: ___________
Patient Initials: _____________
ICD - Diagnosis Codes
______________
______________
______________
______________
______________
______________
Core DME Panel : Tested genes include CYP2D6, CYP2C9, CYP2C19, CYP3A4, and CYP3A5. These genes affect the metabolism of a wide
variety of drugs, including several TCAs, benzodiazepines, opiates/opioids, muscle relaxants, and others.
ChemoDME Panel : Tested genes include TPMT, DPYD, and part of the UGT family. These genes control the metabolism of several
chemotherapeutic agents.
Warfarin Panel : Tested genes include VKORC1, GGCX, CYP4F2, CACNA1C and CYP2C9. These genes are associated with warfarin response.
MTHFR : Affects vitamin B12 and folate metabolism.
Medications of Interest
Acenocoumarol
Alprazolam
Amitriptyline
Amoxapine
Amphetamine
Apixaban
Aripiprazole
Asenapine
Atomoxetine
Azathioprine
Buprenorphine
Buspirone
Capecitabine
Carbamazepine
Carisoprodol
Celecoxib
Chlorpromazine
Citalopram
Clomipramine
Clonazepam
Clopidogrel
Clozapine
Codeine
Cyclobenzaprine
Cyclophosphamide
Desipramine
Desvenlafaxine
Diazepam
Diclofenac
Disulfiram
Doxepin
Duloxetine
Escitalopram
Esomeprazole
Fenoprofen
Fentanyl
Flecainide
Fluoxetine
Flurbiprofen
Flunitrazepam
Fluorouracil
Fluvoxamine
Guanfacine
Haloperidol
Hydrocodone
Ibuprofen
Iloperidone
Imipramine
Indomethacin
Irinotecan
Isophosphamide
Ketoprofen
Lansoprazole
Levomilnacipran
Lisdexamfetamine
White - Castle Copy
17
Lorazepam
Lurasidone
Mefenamic Acid
Meloxicam
Mercaptopurine
Methadone
Methylphenidate
Metoprolol
Midazolam
Mirtazapine
Modafinil
Yellow - Physician Copy
Nabumetone
Naproxen
Nortriptyline
Olanzapine
Omeprazole
Oxazepam
Oxycodone
Paliperidone
Pantoprazole
Paroxetine
Phenprocoumon
Pink - Patient Copy
Phenytoin
Piroxicam
Prasugrel
Propafenone
Quetiapine
Risperidone
Rivaroxaban
Sertraline
Sulindac
Tacrolimus
Tamoxifen
Tapentadol
Tegafur
Temazepam
Ticagrelor
Ticlopidine
Thioguanine
Tramadol
Trazodone
Triazolam
Trimipramine
Venlafaxine
Vilazodone
Voriconazole
Vortioxetine
Warfarin
Ziprasidone
Zolpidem
Zuclopenthixol
See Attached
No Drugs Prescribed
DNA REQUISITION FORM CHEAT SHEET
5700 Highlands Parkway, Suite 100
Smyrna, Georgia 30082
678-486-7340 or 855-822-7853
678-486-7350 or 855-922-7853
DNA@ castlemedical.com
D00001
STEP 1. REQUESTING PHYSICIAN
Please check the appropriate name(s) of the physician(s)
requesting the test(s).
STEP 2. PATIENT INFORMATION
A. Last Name
B. First Name D. Middle Initial
:
D. Social Security #
E. Date of Birth F. Sex
Sex:
G. Address: If you leave this area blank you must check “See
Attached” and provide Demographic Documentation
WC/Auto/LOP:
Insurance:
STEP
5. INSURANCE
See Attached
H. Phone & Email Address
Select the insurance/billing type
Client
Bill
: patient/clinic.
Self Pay:
associated
with
the
The information I have provided on this form is accurate. I authorize Castle Medical to release the results of this
testing to the treating physician or facility. I hereby authorize my insurance or other payment benefits to be paid
directly to Castle Medical for services I received. I acknowledge that Castle Medical may be an out-of-network
provider
send
the payment
withsure
my insurer.
I am
also aware
that and
in some
circumstances
my insurer
might
Please
make
that the
patients
signs
dates
the requisition
form
and
initials
in thedirectly
space
to me. Iin
agree
endorse
the insurance
check
and forward to Castle Medical within fifteen days of receipt. I
provided
thetopeel
sticker
(see next
step).
acknowledge that I am responsible for all co-pays and deductibles not covered by insurance or other payors.
STEP 3. PATIENT SIGNATURE AND DATE
STEP 4.
Time:
___________
PATIENT
INITIALS
Collector Initials: ___________
D00001
The patient will need to write their initials on the peel sticker. Please make sure this is completed
Date:information
___________
Patient
Initials:
_____________
when they are filling out their
above. Once completed,
pleast
remove
the peel
sticker and place on top of collection tube.
Specimen Source
STEP 6.
SPECIMEN TYPE
Select
“Buccal
another
Buccal
SwabSwab” unless
______________
type of collection device has been used
to collect sample.
______________
ICD - Diagnosis Codes
STEP
7. DIAGNOSIS
CODES
______________
______________
In order to prove medical necessity the
______________
______________
physician
must provide a reason
for why the
test
is
being
performed.
______________
______________
STEP
8. TEST(S)
REQUESTED
genes include CYP2D6, CYP2C9, CYP2C19, CYP3A4, and CYP3A5.
Core DME
Panel : Tested
These genes affect the metabolism of a wide
variety of drugs, including several TCAs, benzodiazepines, opiates/opioids, muscle relaxants, and others.
ChemoDME
• CORE
DME Panel : Tested genes include TPMT, DPYD, and part of the UGT family. These genes control the metabolism of several
chemotherapeutic
agents.
• CHEMO
DME
• WARFARIN
Warfarin Panel : Tested genes include VKORC1, GGCX, CYP4F2, CACNA1C and CYP2C9. These genes are associated with warfarin response.
Please select the type of test requested by the physician. The options available are:
• MTHFR
MTHFR : Affects vitamin B12 and folate metabolism.
Medications of Interest
STEP 9. MEDICATIONS OF INTEREST
Vilazodone
Acenocoumarol Buspirone
Codeine
Esomeprazole Hydrocodone
Lorazepam
Nabumetone
Phenytoin
Tapentadol
Alprazolam
Cyclobenzaprine
Fenoprofen
Ibuprofen
Lurasidone
Naproxen
Piroxicamwe have
Tegafur
Selecting fromCapecitabine
this list is no longer
a requirement.
In our current
reporting format,
we provide
all the information
compiled Voriconazole
about
Vortioxetine
Temazepam
Amitriptyline
Carbamazepine
Cyclophosphamide Fentanyl
Iloperidone
Mefenamic Acid
Nortriptyline
Prasugrel
relevant medications
without Desipramine
regard to marked
medications.
If your medication
of interest is
not on our report,
please contact
Warfarin
Amoxapine
Carisoprodol
Imipramine
Meloxicam
Olanzapine
Propafenone
Ticagrelor
Flecainide
[email protected]
and
we'll be happy Fluoxetine
to look into it.Indomethacin
Ziprasidone
Amphetamine
Celecoxib
Desvenlafaxine
Mercaptopurine
Omeprazole
Quetiapine
Ticlopidine
Zolpidem
Apixaban
Chlorpromazine
Diazepam
Flurbiprofen
Irinotecan
Methadone
Oxazepam
Risperidone
Thioguanine
Tramadol
Zuclopenthixol
Aripiprazole
Citalopram
Diclofenac
Flunitrazepam Isophosphamide
Methylphenidate
Oxycodone
Rivaroxaban
Trazodone
Asenapine
Clomipramine
Disulfiram
Fluorouracil
Ketoprofen
Metoprolol
Paliperidone
Sertraline
Triazolam
Atomoxetine
Clonazepam
Doxepin
Fluvoxamine
Lansoprazole
Midazolam
Pantoprazole
Sulindac
Trimipramine See Attached
Azathioprine
Clopidogrel
Duloxetine
Guanfacine
Levomilnacipran
Mirtazapine
Tacrolimus
Paroxetine
Venlafaxine
Buprenorphine
Clozapine
Escitalopram
Haloperidol
Lisdexamfetamine Modafinil
Tamoxifen
Phenprocoumon
No Drugs Prescribed
STEP 10. PHYSICIAN SIGNATURE
Please make sure that the Physician who is requesting the test(s) signs and dates the requisition form.
White - Castle Copy
Yellow - Physician Copy
Pink - Patient Copy
18
DNA COLLECTION PROCEDURE
/2!COLLECT
B OC-100
ENGLISH
Procedure for oral sample collection kit:
For In Vitro Diagnostic Use
1
2
10 x
Collection precautions:
Ensure the sponge tip does NOT come into
contact with any surface prior to collection.
Donor should not eat, drink, smoke or chew gum
for 30 minutes before collecting oral sample.
1
Intended use: This product is designed for the
collection of human oral samples.
Contents: Kit contains liquid.
10 x
2
1
2
Storage: 15E30°C
10 x
2
PATIENT CAN NOT
EAT, DRINK, CHEW GUM
OR SMOKE 30 MINUTES
PRIOR TO TEST.
3
4
5
SWAB MUST STAY ON
EACH SIDE OF MOUTH
FOR AT LEAST 30 SECONDS.
10 x
3
4
5
Hold the tube upright to prevent the liquid inside
the tube from spilling. Unscrew the blue cap from
the collection tube without touching the sponge.
10 x
Summary and explanation of the kit:
ORAcollect is a self-collection kit that provides
the materials and instructions for collecting
human oral samples.
Label legend:
4
10 x
Gently repeat rubbing motion on the opposite side
of the mouth along the lower gums for an additional
10 times.
Warning and precautions: Choking hazard.
Caution should be used when inserting sponge
into the mouth.
Wash with water if liquid comes in contact
with eyes or skin. Do not ingest.
See MSDS at www.dnagenotek.com
3
Open package and remove collector without touching
sponge tip. Place sponge as far back in the mouth as
comfortable and rub along the lower gums (see close
up image) in a back and forth motion. Gently rub the
gums 10 times. If possible, avoid rubbing the teeth.
3
10 x
4
5
Turn the cap upside down, insert the sponge into
the tube and close cap tightly.
B
Catalog number
2
In vitro diagnostic medical device
"
CE Marking
10 x + 10 xManufacturer
. Authorized Representative
E Storage instructions
10 x
Industrial Design Patent
&
3
Collect sample by (Use by)
4
For donor collection instructions in other
languages, see http://dnagenotek.com/
DNA_Genotek_Support_Lit_UI_OC-100.html
5
Invert the capped tube and shake vigorously 10 times.
10 x
Made in Canada
+ DNA Genotek Inc.
Ottawa, ON, Canada K2K 1L1
Tel.: 613.723.5757
[email protected]
www.dnagenotek.com
19
Superior samples • Proven performance
U.S. Patent No. 7,482,116; European Patent No. 1 513 952
and patents pending;
.
Emergo Europe
Molenstraat 15, 2513 BH The Hague, The Netherlands
Tel: (+31) (0) 70 345-8570 Fax: (+31) (0) 70 346-7299
© 2011 DNA Genotek Inc., all rights reserved.
PD-PR-172 Issue 2/2011-03
2"
1
DNA COLLECTION PROCEDURE
/2!COLLECT
Background
B OC-100
For In Vitro Diagnostic Use
OraCollect is an easy, minimally-invasive DNA collection technique that is stable for long periods at room temperature before and after collection. The collection sponge is attached to a reversible cap, minimizing the risk of
contamination.
To reduce the chances of sample rejection due to contamination or low DNA yield, please follow these instructions
carefully, especially steps 1 and 7. Please do not refrigerate collection kits at any time, as this can decrease DNA
yield. Store kits at ambient temperature and out of direct sunlight.
We strongly prefer that clients send both a requisition form and a sample tube for each test ordered. For example,
when requesting both the Core DME panel and MTHFR testing, please send two requisitions
and two sample
Collection precautions:
tubes. We are often able to run multiple tests from the same sample, but this requires
a
good
dealtipofdoes
extra
Ensure the sponge
NOT come into
processing and may cause delays in the release of results.
contact with any surface prior to collection.
Procedure
1
Donor should not eat, drink, smoke or chew gum
for 30 minutes before collecting oral sample.
1. Ensure that the donor does not eat, drink, smoke, or chew gum for at least 30 minutes before collection. During
Intended use: This product is designed for the
the collection procedure, the sponge tip should never come into contact with any surface
than
inside of
collectionother
of human
oralthe
samples.
the collection tube and the inside of the donor’s mouth. Collectors must wear a fresh pair of disposable gloves for
10 x
Contents: Kit contains liquid.
each collection to reduce the risk of contamination.
Warning and precautions: Choking hazard.
Cautioncontact
should be with
used when
inserting sponge
minimize
the sample.
into the mouth.
2. Observe and instruct the donor during collection to ensure compliance, but
The collector may assist donors that are unable to comply with instructions. If you ever suspect that a sample has
Wash with water if liquid comes in contact
been contaminated or mislabeled, discard the kit and start again.
1
2
with eyes or skin. Do not ingest.
See MSDS at www.dnagenotek.com
3. Open the collection kit and remove the collection unit without touching the sponge or the shaft. Be extra
Storage: 15E30°C
cautious to only handle the outside of the tube.
10 x
4. The goal of this collection kit is to soak up saliva, not to scrape cells off of the
focus on areas where saliva pools naturally.
1
10 x
Summary and explanation of the kit:
cheeks
or gums.
Have the
patient
ORAcollect
is a self-collection
kit that
provides
the materials and instructions for collecting
human oral samples.
2
3
5. Ask the patient if he or she is experiencing dry mouth. If the patient has trouble Label
producing
legend: saliva, ask him or her
to think about food before collecting. If the patient’s mouth is still dry, apply a small amount of pure sugar to the
B
Catalog number
tip of the tongue – this won’t affect the test’s results. Do not use candy, as the dyes2
can interfere
with the test.
In vitro diagnostic medical device
"
CE Marking
10along
x + the
10 xlower
6. Insert the sponge into the lower cheek as shown in the collection kit and rub
gums with only
Manufacturer
. Authorized Representative
light pressure.
E Storage instructions
7. Rub slowly, no fewer than 10 times, for a total of at least 30 seconds. Avoid rubbing teeth if possible. Repeat
&
Collect sample by (Use by)
the process on the other side of the mouth with the other side of the sponge, for a total of at least one minute of
For donor
collection
collection. Spending at least one entire minute on collection is essential for achieving
usable
DNAinstructions
yields. in other
Industrial Design Patent
1
2
3
4
languages, see http://dnagenotek.com/
DNA_Genotek_Support_Lit_UI_OC-100.html
8. Hold the tube upright and unscrew the cap from the tube, taking care not to touch the sponge tip or shaft.
x and
10tighten.
x
Invert the cap, replace it with the sponge end inside the10
tube,
9. Hold the closed tube cap-side-down and shake vigorously 15 times, watching for leakage. This important step
makes sure that cells are completely immersed in the liquid that will preserve them.
10. Affix an identifying label to the tube that contains at least the patient’s name, date
ofCanada
birth, and date of collecMade in
+ DNA
Genotek
Inc.
tion. The specimen is now stable at ambient temperature for at least one month and
can
be shipped
without
Ottawa, ON, Canada K2K 1L1
special concern. Do not refrigerate the sample or store it in direct sunlight.
Tel.: 613.723.5757
[email protected]
www.dnagenotek.com
side
pouch. Your
11. Put the tubes in the specimen collection bag and attach the requisition in the
sample is now
ready for shipping or pickup.
Superior samples • Proven performance
20
CASTLE MEDICAL, LLC
Patient: NEWREPORT, FAKEPATIENT
DOB: 01/02/1803
Gender: N/P
Client: CASTLE MEDICAL, LLC
Client #: 1
Doctor: ROY CLARK MD
Chart #:
5700 HIGHLANDS PKWY SUITE 100
SMYRNA, GA 30082-5142
PHONE: 678-486-7340 or 855-822-7853
FAX: 678-486-7350 or 855-922-7853
EMAIL: [email protected]
DIRECTOR: JOHN D. ROBACK, MD, PH.D.
TECHNICAL SUPERVISOR: JAMES RITCHIE, PH.D.
LISH
edure for oral sample collection kit:
package and
remove collector
without
touching Summary
GeneticOpen
Quick
Look
Results
2Testing
4
sponge
tip. Place sponge as far3
back in the mouth as
normalthe lower gums (see close
CYP2C9 comfortable and rub along
CYP2C19
*1/*1
*1/*1
up image) in a back and forth motion. Gently rub the
Genotype: gums
*1/*310 times. If possible, avoid rubbing
Genotype:
the teeth. *1/*1
10 x
normal
10 x
Genotype:
normal
*1/*1
*4-like/*5
10 x
Phenotype: Poor Metabolizer
Enzyme
Function:
Enzyme
Function:
Enzyme
Function:
Moderate loss of enzyme
function
3
Acenocoumarol
Phenprocoumon 1
Warfarin
ANTICONVULSANTS
Phenytoin 1
Normal enzyme function
4
TRICYCLIC
ANTIDEPRESSANTS
Trimipramine 1
BENZODIAZEPINES
Diazepam 1
CARDIOVASCULAR
(P) Clopidogrel
MUSCLE RELAXANTS
(P) Carisoprodol
NSAIDs
Celecoxib
NSAIDs
Hold the tube upright to prevent the liquid
inside
Diclofenac 1
(P) Nabumetone 2, 3
Flurbiprofen the tube from spilling. Unscrew the blue cap
from
Ibuprofen
OPIATES/
OPIOIDS
sponge.
Indomethacin the collection tube without touching the
Methadone 2, 3
Ketoprofen 2, 3
Mefenamic Acid
Meloxicam 1
PROTON PUMP
Naproxen
INHIBITORS
Piroxicam
(P*) Esomeprazole 1
(P*) Lansoprazole 1
(P*) Omeprazole 1
(P*) Pantoprazole
4
5
SSRIs
Citalopram 1
Escitalopram 1
Sertraline 2, 3
TRIAZOLE
ANTIFUNGALS
Voriconazole
10 x
TRICYCLIC
ANTIDEPRESSANTS
Amitriptyline 1
Doxepin 1
Trimipramine 1
10 x
4
Severe loss of enzyme function
USE MORE FREQUENT SERUM MONITORING
MAY CAUSE SERIOUS ADVERSE EFFECTS
5
Phenytoin 1
Sertraline 2, 3
BENZODIAZEPINES
Diazepam 1
3
CYP2D6
Phenotype: Extensive Metabolizer
of the mouth along the lower gums for an additional
10 times.
ANTICOAGULANTS
ANTICONVULSANTS
SSRIs
0x
Specimen Type: BUCCAL SWAB
Phenotype: Intermediate Metabolizer
USE WITH CAUTION
rubbing
motion on the opposite side USE AS DIRECTED
MAYGently
CAUSErepeat
ADVERSE
EFFECTS
2
5
Lab Accession: 1507021067
Accessioned: 07/02/15 17:30
Collected: 07/02/15
Reported on: 07/10/15 by: ALEX
5
Turn the cap upside down, insert the sponge into
the tube and close cap tightly.
ADHD THERAPY
Amphetamine
Atomoxetine
ANTIARRHYTHMIC
Flecainide
Propafenone
ANTIHYPERTENSION
Metoprolol
NSAIDs
(P) Nabumetone 2, 3
OPIATES/ OPIOIDS
(P) Codeine
Hydrocodone
Methadone 2, 3
(P) Tramadol
TRICYCLIC
ANTIDEPRESSANTS
Amitriptyline 1
Clomipramine
Desipramine
Doxepin 1
Imipramine 1
Nortriptyline
Trimipramine 1
TYPICAL /ATYPICAL
ANTIPSYCHOTICS
Aripiprazole 1
Chlorpromazine
Haloperidol 1
Iloperidone 1
Olanzapine 3
Risperidone
Zuclopenthixol
OTHER
ANTIDEPRESSANTS
Amoxapine
Vortioxetine
SNRIs
Duloxetine
Venlafaxine
SSRIs
Escitalopram 1
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline 2, 3
10 x
5
Invert the capped tube and shake vigorously 10 times.
These drugs have more than one major pathway. It is recommended to check all relevant enzymes before making dosage decisions.
These drugs have more than one minor pathway. It is recommended to check all relevant enzymes before making dosage decisions.
3 The major metabolic pathways for these drugs are not tested. Phenotypic variation will have a less pronounced effect.
(P )These drugs are prodrugs, meaning that they are inactive until they are metabolized. Poor or intermediate metabolizers may experience reduced therapeutic effect.
(P*)These prodrugs are activated by stomach acid rather than enzymes. For the purposes of this report, they may be considered as if they were not prodrugs.
For a more detailed list of drug metabolism pathways, including minor pathways and supporting references, please see www.castlemedical.com/DNA.
1
2
10 x
U.S. Patent No. 7,482,116; European Patent No. 1 513 952
and patents pending;
.
Emergo Europe
Molenstraat 15, 2513 BH The Hague, The Netherlands
Tel: (+31) (0) 70 345-8570 Fax: (+31) (0) 70 346-7299
This specimen was analyzed using qPCR of DNA extracted samples for gene mutations that lead to loss or gain of enzyme function.This test was developed and its performance characteristics determined by Castle Medical LLC. It
has not been cleared or approved by the FDA. The laboratory is regulated and accredited by CLIA and the College of American Pathologists (CAP) as qualified to perform high-complexity testing. This test is used for clinical
DNA
Genotek Inc.,
all research.
rights reserved.
purposes. It should not©be2011
regarded
as investigational
or for
For a list of all alleles detected, see www.castlemedical.com/DNA.
21
PD-PR-172 Issue 2/2011-03
2"
CASTLE MEDICAL, LLC
(855)822-7853 Page 1
CASTLE MEDICAL, LLC
5700 HIGHLANDS PKWY SUITE 100
SMYRNA, GA 30082-5142
PHONE: 678-486-7340 or 855-822-7853
FAX: 678-486-7350 or 855-922-7853
EMAIL: [email protected]
DIRECTOR: JOHN D. ROBACK, MD, PH.D.
TECHNICAL SUPERVISOR: JAMES RITCHIE, PH.D.
Patient: NEWREPORT, FAKEPATIENT
DOB: 01/02/1803
Gender: N/P
Client: CASTLE MEDICAL, LLC
Client #: 1
Doctor: ROY CLARK MD
Chart #:
Lab Accession: 1507021067
Accessioned: 07/02/15 17:30
Collected: 07/02/15
Reported on: 07/10/15 by: ALEX
Specimen Type: BUCCAL SWAB
Supplementary Information - Known Inducers and Inhibitors
CYP2C9
INHIBITORS
Amiodarone
Capecitabine
Cotrimoxazole
Diltiazem
Etravirine
Fluconazole
Fluoxetine
Fluvastatin
Fluvoxamine
Ketoconazole
Metronidazole
Miconazole
Oxandrolone
Rosuvastatin
Sertraline
Sulfinpyrazone
Tigecycline
Verapamil
Voriconazole
Zafirlukast
CYP2C19
INDUCERS
Aprepitant
Bosentan
Carbamazepine
Hyperforin - (St. Johnʼs
Wort)
Phenobarbital
Rifampin
INHIBITORS
Allicin (garlic derivative)
Armodafinil
Carbamazepine
Cimetidine
Cyclosporine
Esomeprazole
Etravirine
Felbamate
Fluconazole
Fluoxetine
Fluvoxamine
Human growth hormone (rhGH)
Ketoconazole
Miconazole
Moclobemide
Nicardipine
Omeprazole
Oral contraceptives
Ticlopidine
Voriconazole
CYP2D6
INDUCERS
Acetylsalicylic acid (low-dose aspirin)
Artemisinin
Dexamethasone
Rifampin
INHIBITORS
Amiodarone
Bupropion
Celecoxib
Cimetidine
Cinacalcet
Cyclosporine
Diltiazem
Diphenhydramine
Duloxetine
Febuxostat
Fluoxetine
Gefitinib
Hydralazine
Hydroxychloroquine
Imatinib
Methadone
Moclobemide
Nicardipine
Norfloxacin
Paroxetine
Phenelzine
Quinidine
Ranitidine
Ritonavir
Saquinavir
Sertraline
Terbinafine
Ticlopidine
Verapamil
INDUCERS
No verified inducers known
The use of medications and other chemicals that induce and inhibit enzymes can lead to a temporary change in metabolizer phenotype. The use of inhibitors will reduce a patientʼs
metabolic activity in that enzyme, while the use of inducers will increase it. Inducers and inhibitors can change the dosage of medications required in achieve therapeutic effect.
Please refer to www.castlemedical.com/DNA for more complete list and reference citations.
This list, which will appear in every report, will help warn physicians about potential drug interactions.
Please feel free to contact the DNA department at [email protected] or (678) 486-7340 x. 641.
This specimen was analyzed using qPCR of DNA extracted samples for gene mutations that lead to loss or gain of enzyme function.This test was developed and its performance characteristics determined by Castle Medical LLC. It
has not been cleared or approved by the FDA. The laboratory is regulated and accredited by CLIA and the College of American Pathologists (CAP) as qualified to perform high-complexity testing. This test is used for clinical
purposes. It should not be regarded as investigational or for research. For a list of all alleles detected, see www.castlemedical.com/DNA.
CASTLE MEDICAL, LLC
(855)822-7853
22
ONLINE SUPPLY
ORDERING
1. Visit www.castlemedical.com/order
2. Select the Supply Order Form by clicking in the center of the box
or the hyperlink text below the image.
3. A new pop-up window will open. Follow the easy-to-use order form
and select the appropriate supplies as needed, including:
•
•
•
•
•
23
DNA Kits
P.O.C. (Point-Of-Care) Cups
Clinical Packs
Swabs
Specimen Bags
ONLINE RESULT
INQUIRY
1. Visit www.castlemedical.com and click the Login button at the top right corner of your screen.
2. Enter your unique login credentials to access your reports.
3. At the next screen click on Result Inquiry.
4. You can search results by:
a. First & Last Name
b. Order Date or Collection Date
c. Both Name & Date for More Specific Results
5. Once you have entered the pertinent information click
Start Search to begin the search process.
6. You will now be able to see:
a. Patient Name
b. Test Date
c. Sample Collection Date for the Patient
d. The Accession #
e. Date of Birth
f. Client that Ordered the Result
7. To view the results of a specific patient click on their name (either first or last).
Note: If a report is Pending please be advised that a certifying scientist is working on results and it will
be considered “incomplete”until further notice.
24
ONLINE WEB
ORDERING
1. Visit www.castlemedical.com and click the Login button at the top right corner of your screen.
2. If you have not received login credentials for your client(s) patient results, please contact Customer
Service as they can provide you with a unique login.
3. Select New Test Order from the navigation pane on the left hand side of your screen. This will bring
up a new tab called Orders.
4. If a patient has received Castle Medical services in the
past, you can search by Patient’s first and last name
and then click search. If you cannot locate a patient
using this method please continue to Step 5.
5 Select Click Here To Add A New Patient.
5
25
ONLINE WEB ORDERING
5. This will take you to the Patient Information tab. Please be sure to fill out all required fields in green.
6. Once finished entering the patient information, click Save & Continue at the bottom of the page.
7 You will now be directed to the
Insurance Info Tab. Here you
can click the Same as patient
option if you would like to
populate the patient’s info
from the previous page.
7a
To lookup patient’s insurance
provider click “Lookup Insurance
Code”and type insurance name.
Select insurer with same address
listed on the back of the card.
7b
If Castle Medical is billing the
client for services, please select
Bill Client. A client-bill agreement
must be on file to select this option.
7c
7
7a
7b
7c
8
If the patient is a self-pay patient
please select Bill Patient. If you
select this option you can
continue to Step 9.
8 Please note that there are two
sections; primary insurance and
secondary insurance. If a patient
only provides a primary insurance
card, you will only need to fill out the primary section. If two cards are provided, please be sure to
fill out primary insurance information on the left and secondary info on the right.
9. Click Save/Continue once completed.
26
ONLINE WEB ORDERING
9. On the Specimen Info tab, please be sure to fill-in all required items marked in green. For Source,
the options are as follows: Urine, Blood or Saliva. Please be sure to click Save/Continue.
10. On the Test Info tab, you will be required to enter the type of test you would like Castle to run. You
will have the option to add a Test By Code, search by Test Name or input Special Test Instructions.
11. Once you have added all tests to the list click, Save & Continue.
Note: If a Test Order Questionairre appears, please select Cancel to proceed to the next page.
12. Next, you will need to enter Diagnosis Info. You can enter as many diagnosis codes as are
considered medically necessary.
27
ONLINE WEB ORDERING
13. If you need to lookup the diagnosis code for the patient click the Search By Description button and
enter the patient diagnosis, select the correct diagnosis from the list.
14. Click the Finish Button.
15. The Prescribed Medication page will pop-up. Be sure to select all prescriptions that the patient
is currently prescribed.
15a
15a
If prescribed medication is unknown or no medication is prescribed, please select appropriate boxes.
16. After clicking Save from this screen an electronic requisition and four (4) labels will automatically print.
17. Be sure to take the labels and:
a . Place one (1) on top of the lid.
b. Place one (1) on the side of the cup.
c . Place the remaining (2) on any additional
documentation.
18. Please be sure that both Patient and
Physician sign the printed electronic
requisition before sending.
19. Once all orders have been entered, click the
“order log” button under the menu. Select the
date of the log that corresponds with the
samples that are being sent and click
“Start Search.” Click the print button at the
bottom of the page.
sample
electronic requisition
28
the importance of MEDICAL
NECESSITY
Medical necessity is defined as accepted health care services and supplies provided by
health care entities, appropriate to the evaluation and treatment of a disease, condition,
illness or injury and consistent with the applicable standard of care.
COMMON DIAGNOSES THAT PROVE MEDICAL NECESSITY
Reporting poor pain control despite high doses of med.
Family history of substance abuse
Patient has history of abuse
Taking prescription narcotics from multipe providers
Patient has drug dependence issues
Report of selling prescription drugs
Unapproved use of drug to treat non-pain symptoms
Suspicion of continued substance abuse
Patient has an unreliable history
Obtaining drugs from a non-medical source
Borrowing medications from someone else
Suspected drug abuse
Patients that may present high risk
or synergentic interactions with
prescribed medications
History of moderate to high alcohol use
Drug hoarding (taking less than prescribed)
Preliminary screen inconsistent with self-report
Treatment for chronic
opioid therapy
Frequent prescription losses
Unspecified drug dependence
questions to ask yourself...
1. Is your medical record proving proper
medical necessity?
If you don’t know the what,
and you don’t know the why,
then your medical record
just won’t fly.
2. Are you documenting why the test(s)
are being ordered for your patient(s)?
PLE
SAM
3. Are you documenting what tests are being ordered?
urinetheknow
29
W
the
If you don’t know the what,
and you don’t know the why,
then your medical record
just won’t fly.
test
CAN YOU ANSWER THE FOLLOWING QUESTIONS?
WHY ARE
YOU TESTING?
Patient has an unreliable history
WHAT
ARE YOU
TESTING?
SCREENING?
Suspected drug abuse
CONFIRMATION?
Patient has history of abuse
Suspicion of continued
substance abuse
Present high risk or
synergistic interactions
with prescribed
medications
Treatment for chronic
opioid therapy
BOTH?
the
Wtest
TESTING FOR:
MDMA • PCP • TCAs
THC • Alcohol
Amphetamines
Barbiturates
Buprenorphine
Benzodiazepines
Cocaine • Opiates
Methamphetamines
Methadone
Oxycodone
WHEN ARE YOU TESTING?
The patient’s diagnosis will determine
how often they should be treated.
30
urinegoodcompany