Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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