Note: All information with a red asterisk ( * ) must be completed

Patient Information
Month: Day: Year:
Physician Information
Active Medication List

Billing Information

Specimen Information
When ordering tests, the provider is required to make an independent medical necessity decision with regard to each test the laboratory will bill. The provider also understands he or she is required to (1) submit diagnosis codes supported in the patient’s medical record as documentation of the medical neccesity or (2) explain and have patient sign an ABN.

Icd 10 codes Icd 10 code description Action
CPOC Test Results

Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option
Order Panel


Mark all that apply (If not marked, specimen will be returned)

Best Practices

Testing for drugs of abuse and adherence to the treatment plan is a recognized best practices component of proper management when COT is involved. Valid risk assessment and PMP are noted in patients medical records.

Baseline Test

Confirmation required to confirm patient's documented history.

Periodic Monitoring

Random drug test for current medications prescribed and to rule out abuse/diversion and use of illicit drugs in accordance with patient's risk rating as documented in medical records.

High Risk Patient

High risk by suitable psychological assessment requiring increase testing frequency.

Targeted Testing

Patient presents with suspicious non-compliant behaviors as documented in medical records.

Confirmation Required

(+) Qualitative results

Confirmation required due to absence of reliable validation from patient, required by manufacturer instructions, and to identify the substance causing the positive result.

Confirmation Required

(-) Qualitative results

Exception - Confirmation required as patient is actively being prescribed medications that failed to appear on Qualitative test.


Confirmation required to confirm discontinuation of THC in accordance to a treatment plan.

Inadequate Detection

Suspected use of a substance that is inadequately detected or not detected by qualitative testing.



The ordering authorized Health Care Provider understands and hereby acknowledges that (a) the tests ordered are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s clinical file and that the Health Care Provider is responsible for assigning Read more


For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

By selecting the Add Signature button, I attest that I approve of this digital signature

By my signature below I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however such results shall be used solely for clinical diagnostic/treatment purposes only and shall not be used for any forensic purposes related to my Read more
Insurance Detail
Testing Option
Physician Signature Not Available

Physician Signature / Date


Patient Signature / Date