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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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Icd 10 gem codes Icd 10 gem code description Action
Testing Option

PHYSICIAN SIGNATURE:

I hereby request and authorize the laboratory or its affiliates to utilize this information to perform testing for the indicated patient. I certify that I have explained the test to the patient. I also certify that I will only use and disclose test results as permitted by law. I certify that the tests ordered on this form are medically necessary Read more

PATIENT SIGNATURE:

I request and authorize the Laboratory to perform the designated test(s) on the sample provided by me. My signature below constitutes my acknowledgment that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional. Read more
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