DNA/ Urine Req Forms

Transcription

DNA/ Urine Req Forms
Gold Star Laboratories / 5000 Birch Street / West Tower 3000 / Newport Beach, CA 92660 / P: 1 888 474 4994 / F: 1 714 464 4455
Pathology Laboratory Services
3089 South Harbor Blvd
Santa Ana, CA 92704
CLIA: 05D0580198
Lab Director: Dr. Cyrus Karimi
L a b o r a t o r i e s
PRACTICE
PHONE #
PATIENT LAST NAME
PATIENT FIRST NAME
MyLab
448 Sovereign Ct.
St. Louis, Missouri 63011
CLIA: 26D2052246
Lab Director: Steve Howard
ADO Health Services
1011 Boardman-Canfield Road
Youngstown
Ohio 44512
CLIA: 36D2068849
Lab Director: Dr. Neil Quigley
B3 Laboratory
24555 Southfield Rd.
Suite L-60
Southfield, MI 48075
CLIA: 23D2097180
Lab Director: Fares Masri
ORDERING PHYSICIAN
FAX #
Advanced Genomics
4939 De Zavala, Suite 101
San Antonio, TX 78249
CLIA: 45D2092474
Lab Director: Dr. Robert Bredt
NPI
MIDDLE INITIAL DATE OF BIRTH GENDER
Female
Male
CITY
STREET ADDRESS
STATE
ZIP
PHONE #
SOCIAL SECURITY
ETHNICITY
Hispanic/Latino
American Indian/Native Alaskan
White
Mixed Race
PATIENTS CURRENT MEDICATION
Asian
Black
Unknown/Other
Hawaiian/Pacific Islander
I order the lab to test for/confirm the prescribed medications listed below
o Actiq
o Butabital
o Doxepin
o Klonopin
o MS Contin
o Oxycontin
o Roxicet
o Ultracet
o Adapin
o Butrans
o Duragesic
o Lorazepam
o MSIR
o Oxymorphone
o Roxicodone
o Ultram
o Adderall
o Carisoprodol
o Elavil
o Lorcet/Lortab
o Mysoline
o Pamelor
o Serax
o Valium
o Alprazolam
o Celexa
o Endocet
o Lunesta
o Naloxone
o Paxil
o Soma
o Vicodin
o Ambien
o Clonazepam
o Exalgo
o Lyrica
o Naltrexone
o Percocet
o Suboxone
o Vicoprofen
o Amitriptyline
o Codeine
o Fentanyl
o Marijuana
o Neurontin
o Percodan
o Subutex
o Vyvanse
o Amphetamine
o Concerta
o Fioricet/Fiorinal
o Marinol
o Norco
o Percolone
o Sulfate
o Xanax
o Amrix
o Darvon
o Flexeril
o Maxidone
o Nortriptyline
o Pertofrane
o Tapentadol
o Zohydro ER
o Ativan
o Demerol
o Flurazepam
o Meperadine
o Nucynta
o Phenobarbital
o Temazepam
o Zoloft
o Aventyl
o Desipramine
o Gabapentin
o Methadone
o Opana
o Pregabalin
o Tramadol
o Zolpidem
o Avinza
o Dexedrine
o Halcion
o Methadose
o Oramorph
o Prozac
o Tussionex
o Zydone
o Buprenex
o Diazepam
o Hydrocodone
o Midazolam
o Oxazepam
o Restoril
o Tylenol #3
o Other
o Buprenorphine
o Dilaudid
o Hydromorphone o Morphine
o Oxy IR
o Ritalin
o Tylenol #4
o List Attached
o Butabarbital
o Dolophine
o Kadian
o Oxycodone
o Roxanol
o Tylox
o No Prescribed Med
PRIMARY INSURER
NAME OF INSURED
PRIMARY INSURER PHONE #
RELATIONSHIP
Self
SECONDARY INSURER
NAME OF INSURED
o Morphine
GROUP #
MEMBER ID
ADDRESS, CITY, STATE AND ZIP
Parent
Spouse
SECONDARY INSURER PHONE # MEMBER ID
RELATIONSHIP
Self
GROUP #
ADDRESS, CITY, STATE AND ZIP
Parent
PHONE #
PHONE #
Spouse
SPECIMEN(S) TO BE TESTED
Urine
DNA
Blood
Other
PHYSICIANS ACKNOWLEDGEMENT
In my professional judgment, the tests I order for this patient are medically necessary. I also understand that each test I have ordered is a billable
event and that my order and requisition are required for each specimen sent to Goldstar Laboratories.
Further, I understand that the patient's medical records must clearly reflect my order for testing.
PHYSICIANS SIGNATURE
DATE
URINE
PATIENT FIRST NAME
PATIENT LAST NAME
ORDERING PHYSICIAN
PRIMARY DIAGNOSIS CODES
SOCIAL SECURITY
SECONDARY DIAGNOSIS CODES
Z79.899 Long-term (current) use of other medications
Z79.891 Long-term (current) use of opiate
Z51.81
Encounter for therapeutic drug monitoring
OTHER
POC PERFORMED
TEMPERATURE
Yes
Medication/ Drug
Amphetamine
Barbiturate
Benzodiazapine
Buprenorphine
Cocaine
Methadone
Methamphetamine
+/o o
o o
o o
o o
o o
o o
read within 4 mins in the range 91 - 99.6 F
No
Medication/ Drug
MDMA
Opiates
Oxycodone
PCP
TCA
THC
+/-
PANEL - CONFIRM ONLY
o o
Yes
No
if No, actual temp
PANEL - SCREEN & CONFIRM
Positive & inconsistent
Negatives
Comprehensive
o o
Standard
o o
o o
Basic
o o
o o
Custom
o o
ADDITIONAL TESTING REQUESTED
o Amphetamines
o Ecstacy
o Methylphenidate
o Bath Salts
o Barbiturates
o Fentanyl
o Opiates
o Ethanol (EtOH)
o Benzodiazepines
o Gabapentin
o Opiate Metabolites
o Ketamine
o Buprenorphine
o Heroin
o Phencyclidine
o Lunesta
o Carisprodol
o MDMA
o Pregabalin
o Synthetic Cannabinoids
o Cathinones
o Meperidine
o Tapentadol
o Tricyclic Antidepressents
o Cocaine
o Methadone
o THC
o Triazolam
o Metabolite
o Methamphetamine d/I
o Tramadol
o Zolpidem
NOTES
CONSENT
I certify that I have voluntarily provided fresh and unadulterated specimens for testing and that the information provided on this form and on the label
affixed to the specimens is accurate. I authorize Goldstar Laboratories to release the results of the tests to the ordering physician or practice listed
above. I further authorize Goldstar Laboratories to fill my insurance plan and for any benefit to be paid directly to Goldstar Laboratories for the
services received. I authorize my practitioner and my insurance company to release to Goldstar Laboratories and to its agents any information
needed to determine insurance benefits for the services received. If I am a self-pay/cash patient, then I accept full responsibility for all charges
associated with the services received.
PATIENTS SIGNATURE
DATE
COLLECTOR NAME
COLLECTION DATE
SPECIMEN BARCODE
DNA
PATIENT LAST NAME
PATIENT FIRST NAME
ORDERING PHYSICIAN
SOCIAL SECURITY
DIAGNOSIS CODES - CYP2C19 & CYP2CD6
Cardiovascular
o E78.0 Pure hypercholesterolemia
o E78.2 Mixed hyperlipidemia
o E78.5 Hyperlipidemia, unspecified
o I14.91 Unspecified Atrial Fibrillation
o I20.0 Unstable angina
o I20.1 Angina pectoris with documented spasm
o I20.8 Other forms of angina pectoris
o I20.9 Angina pectoris, unspecified
o I21.29 ST elevation (STEMI) Ml involving other sites
o I21.3 ST elevation (STEMI) Ml of unspecified sites
o I21.4 Non-ST elevation (NSTEMI) Ml
o I24.0 Acute coronary thrombosis not resulting in Ml
o I24.1 Dressler's syndrome
o I24.8 Other forms of acute ischemic heart disease
Mental Health
Major Depressive Affective Disorder Recurrent Episod
o F33.9 Unspecified
o F33.0 Mild
o F33.1 Moderate
o F33.2 Severe w/o psychotic features
o F33.3 Severe w/ psychotic features
o F33.41 In partial remission
o F33.42 In full remission
Bipolar I Disorder, Most Recent Episode (or Current)
DEPRESSED
o F31.30 Unspecified
o F31.31 Mild
o F31.32 Moderate
o F31.4 Severe w/o psychotic features
o F31.5 Severe, w/psychotic features
o F31.75 In partial remission
o F31.76 In full remission
Bipolar I Disorder, Most Recent Episode (or Current)
MIXED
o F31.60 Unspecified
o F31.61 Mild
o F31.62 Moderate
o F31.63 Severe, w/o psychotic features
o F31.64 Severe, w/psychotic features
o F31.77 In partial remission
o F31.78 In full remission
o G1O Huntington's disease
o Additional ICD-10 codes (add here):
DIAGNOSIS CODES - All Assays except CYP2C19 & CYP2CD6
Cardiovascular
o D68.2 Hereditary deficiency of other clotting factors
o I10 Essential (primary) hypertension
o I25.9 Chronic ischemic heart disease, unspecified
o I48.91 Unspecified atrial fibrillation
o I50.9 Heart failure, unspecified
o I82.91 Chronic embolism and thrombosis,
unspecified vein
o R03.0 Elevated blood-pressure reading, w/o
diagnosis of hypertension
Mental Health
o F41.9 Anxiety disorder, unspecified
o F32.9 Major depressive disorder, single episode,
unspecified
o F90.9 Attention deficit hyperactivity disorder,
unspecified
Nervous System
o G43.909 Migraine, unspecified, not intractable, w/o
status migrainosus
o G44.1 Vascular headache, not elsewhere classified
Digestive
o K21.9 Gastro-esophageal reflux disease w/o
esophagitis
Other
o T50.905A Adverse effect of unspecified drugs,
Pain
o G89.18 Other acute post procedural pain
o G89.4 Chronic pain syndrome
o M12.9 Arthropathy, unspecified
o M15.9 Polyosteoarthritis, unspecified
o M19.90 Unspecified osteoarthritis, unspecified site
o M25.50 Pain in unspecified joint
o M25.569 Pain in unspecified knee
o M54.5 Low back pain
o M60.9 Myositis, unspecified
o M79.1Myalgia
o M79.7 Fibromyalgia
o M79.609 Pain in unspecified limb
o M53.82 Other specified dorsopathies, cervical region
o Additional ICD-10 codes (add here):
medicaments & biological substances, initial encounte
Endocrine System
o E03.9 Hypothyroidism, unspecified
o E10.9 Type 1 diabetes mellitus w/o complications
o E11.9 Type 2 diabetes mellitus w/o complications
o Z79.891 Long term (current) use of opiate analgesic
o Z79.899 Other long term (current) drug therapy
Other intervertebral Disc Degeneration:
Signs & Symptoms
o G93.3 Post viral fatigue syndrome
o R00.2 Palpitations
o RO6.00 Dyspnea, unspecified
o R06.09 Other forms of dyspnea
o R11.2 Nausea with vomiting, unspecified
o R35.0 Frequency of micturition
o R51 Headache
o R53.1 Weakness
o R53.81 Other malaise
o R53.83 Other fatigue
o R60.0 Localized edema
o R60.1 Generalized edema
Radiculpathy:
o M54.14 Radiculopathy, thoracic region
o M54.15 Radiculopathy, thoracolumbar region
o M54.16 Radiculopathy, lumbar region
o M51.34 Thoracic region
o M51.35 Thoracolumbar region
o M51.36 Lumbar region
o M51.37 Lumbosacral region
TESTING PANEL REQUESTED
Comprehensive
Custom
CYP2B6
CYP2D6
CYP3A4/5
OPRM1
Apoe
Factor II
Factor V
MTHFR
UGT2B15
Other
CYP1A2
CYP2C9
CYP2C19
COMT
ANNK1/DRD2
SLC01B1
VKORC1
MEDICAL NECESSITY
o Patient has a history of medication failure(s)
o There is a ‘Warning’ in the package insert of the medication being considered
o Patient has experienced sensitivity to prescribed medication(s)
o Desired medication for the patient is a ‘controlled substance’
o Patient has experienced lack of symptom relief from prescribed medication(s) o Medication class is new to the patient
o Patient has been non--compliant with prescribed medication(s)
o An inhibitor or inducer may affect therapeutic response to prescribed
medication(s)
RESULTS APPLICATION
o As a component of my medical decision-making as to which medication(s) to
avoid for this patient
o As a component of my medical decision-making as to which medication(s) to
prescribe for this patient
o As a component of my medical decision-making regarding dose initiation or
titration for this patient
o As a component of my medical decision-making to manage patients thrombotic
risk
CONSENT
I agree that I am voluntarily submitting this DNA specimen for analysis and authorize my physician to release the specimen and any other necessary records to Goldstar Laboratories. I authorize
the laboratory to process the specimen and release the results of the tests to the ordering physician or Practice. I understand that Goldstar Laboratories reserves the right to re-collect such
specimens as necessary and store such specimens for future tests. I authorize Goldstar Laboratories to submit a claim for payment for the services along with any necessary records to my
insurer or to Medicare for the purposes of collecting payment. I understand that if my insurance provider remits payment directly to me, I will forward such payment immediately to Goldstar
Laboratories. I further understand that I am responsible for any and all charges not recovered from my insurance provider, including any deductible, copayment or coinsurance as indicated by
my insurer. I acknowledge I have received pretest counseling to understand the purposes of the DNA test being performed, including the risks as well as the effect of the results.
PATIENTS SIGNATURE
DATE
COLLECTOR NAME
COLLECTION DATE
SPECIMEN BARCODE
BLOOD
PATIENT FIRST NAME
PATIENT LAST NAME
ORDERING PHYSICIAN
SOCIAL SECURITY
DIAGNOSIS CODES
TESTING PANEL REQUESTED
Comprehensive
Annual Wellness + Allergy + Expanded
Allergy
SE (AL, AR, FL, GA, HI, KY, LA, MS, NC, SC, TX, VA)
Annual Wellness
SW (AZ, CO, KS, NM, OK, TX, UT)
Expanded
W (CA, NV)
HIV, HEP B, HEP C, Chlamydia
NW (ID, MT, ND, NE, OR, SD, WA, WY)
NE (CT, DE, IA, IL, IN, MA, ME, MD, MI, MN, MO, NJ, OH, PA, RI, WI, WV)
ALLERGY
ANNUAL WELLNESS
EXPANDED
FEMALE
COMPLETE BLOOD COUNT
85025
COMP METABOLIC PANEL
80053 (AMA DEFINED PROFILE)
LIPID PANEL
80061 (AMA DEFINED PANEL)
APOLIPOPROTEIN A-1
APOLIPOPROTEIN, B-100
TESTOSTERONE,FR/TOT W/SBG
HIV, HEP C and STD
MALE
82172
COMPLETE BLOOD COUNT
85025
82172
COMP METABOLIC PANEL
80053 (AMA DEFINED PROFILE)
84403, 84270
LIPID PANEL
80061 (AMA DEFINED PANEL)
C-PEPTIDE
84681
CHLAM
LIPOPROTEIN a
83695
HIV
86703
APOLIPOPROTEIN A-1
82172
HSV1
86689
82172
HSV 2 - IgG
84403, 84270
87490
BILIRUBIN, DIRECT
82248
DHEA SULFATE
82627
BILIRUBIN, DIRECT
82248
APOLIPOPROTEIN, B-100
FERRITIN
82728
LUTEINIZING HORMONE
83002
FERRITIN
82728
TESTOSTERONE,FR/TOT W/SBG
HSV2 - IgM
86694
VITAMIN B-12
82607
FOLLICLE STIM HORMONE
83001
VITAMIN B-12
82607
DHEA SULFATE
82627
RPR
86592
VITAMIN D, 25-HYDROXY
82306
FREE T3
84481
VITAMIN D, 25-HYDROXY
82306
LUTEINIZING HORMONE
83002
RPR TITER
86593
86694
AMYLASE
82150
PROLACTIN
84146
AMYLASE
82150
FREE T3
84481
HEP C
86804
PHOSPHORUS
84100
HCG QUANTITATIVE
84702
PHOSPHORUS
84100
PROLACTIN
84146
HEP B
87340
HEPBSAG
87340
83735
ESTRADIOL
82670
MAGNESIUM
83735
PROGESTERONE
84144
HEMOGLOBIN A1C
83036
PROGESTERONE
84144
HEMOGLOBIN A1C
83036
TSH
84443
INSULIN
83525
TSH
84443
INSULIN
83525
T3 UPTAKE
84479
GROWTH HORMONE (HGH)
83003
T3 UPTAKE
MAGNESIUM
84479
GROWTH HORMONE (HGH)
83003
T4 FREE
84439
CORTISOL, RANDOM
82533
T4 FREE
84439
CORTISOL, RANDOM
82533
PSA, TOTAL
84153
C-PEPTIDE
84681
URIC ACID
84550
LIPOPROTEIN a
83695
CONSENT
I certify that I have voluntarily provided fresh and unadulterated specimens for testing and that the information provided on this form and on the label
affixed to the specimens is accurate. I authorize Goldstar Laboratories to release the results of the tests to the ordering physician or practice listed
above. I further authorize Goldstar Laboratories to fill my insurance plan and for any benefit to be paid directly to Goldstar Laboratories for the
services received. I authorize my practitioner and my insurance company to release to Goldstar Laboratories and to its agents any information
needed to determine insurance benefits for the services received. If I am a self-pay/cash patient, then I accept full responsibility for all charges
associated with the services received.
PATIENTS SIGNATURE
DATE
COLLECTOR NAME
COLLECTION DATE
SPECIMEN BARCODE

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