Patient Information
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Physician Information
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Specimen Information
The codes below are commonly used to support medical necessity in drug monitoring, but the appropriate code for your patient may be different, the treating physician/provider must provide the most appropriate diagnosis code(s) for your patient.










Icd 10 gem codes Icd 10 gem code description Action
CPOC Test Results


Test Selection

PHYSICIAN SIGNATURE:

Signature on Paper Requisition
Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified during the clinical assessment, and use in the treatment plan is recommended to support medical necessity. Guidance from experts and professional organizations also suggest documentation of a risk Read More

PATIENT SIGNATURE:

Signature on Paper Requisition
I am voluntarily seeking laboratory services and hereby consent to provide a sample as requested for analysis by Advanced Diagnostic Labs. I certify that I have voluntarily provided a fresh and unadulterated urine specimen for analytical testing. The information provided on this form and on the label affixed Read More
PATIENT
PROVIDER
Insurance Detail
COLLECTION DETAILS
DIAGNOSTIC CODES
MEDICATIONS
Testing Option
 
Reflex Confirmation
Confirm All Medications
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Physician Signature / Date

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Patient Signature / Date