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Physician Information
Prescribed Medications
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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.








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CPOC Test Results


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ALCOHOL

AMPHETAMINES






BARBITURATES






PHENCYCLIDINE (PCP)

BENZODIAZEPINES





COCAINE

METHADONE

PROPOXYPHENE

CREATININE

OPIATES





OXYCODONE



PHYSICIAN SIGNATURE:

I understand and hereby acknowledge that the tests ordered herein are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s file. I further acknowledge that all tests will be quantitative unless otherwise indicated on the back of this requisition.

PATIENT SIGNATURE:

I am voluntarily seeking laboratory services and hereby consent to provide a sample as requested. 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 to the specimen cup is accurate. I have the right to refuse specific test, but understand this may impact my treatment. Click Here
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Patient Signature / Date