CLINICAL LAB REQUEST

PT. NO.

After hours & Weekends:

Harborview Medical Center

(206) 744-3451

UW Medical Center

(206) 598-6224

UW MEDICINE
REFERENCE LABORATORY SERVICES

NAME (Last, First)

Toxicology

M
F

NOTE:
REQUIRED
Serum

TYPE

Other

Whole Blood

___ ACETAMINOPHEN

TYL

___ AMIKACIN

__ Peak __ Trough __ Random

AMIKAP, AMIKAT, AMIKAR

___ AMITRIPTYLINE + NORTRIPTYLINE

SENDER SPECIMEN #

___ CAFFEINE

DATE & TIME COLLECTED

Trough

DATE/TIME OF LAST DOSE

RAMNR

CAFQN

___ NORTRIPTYLINE
___ PHENOBARBITAL

___ Total
___ Free & Total

___ DESIPRAMINE

RDESIG

DIG

___ GENTAMICIN

CONCURRENT MEDICATIONS (within 48 hours)

__ Peak __ Trough __ Random

GENTAP, GENTAT, GENTAR

ICD/DIAGNOSIS

___ LIDOCAINE

SEND REPORT TO (Hospital, Clinic, Physician)

LIDO
LI

___ METHOTREXATE

MTX

ASA
SIROL

___ THEOPHYLLINE
___ TOBRAMYCIN

___ LITHIUM

DIL
FTDIL

___ TACROLIMUS (FK506) TACRO

___ THIOCYANATE

LEVET

PHNO

___ SIROLIMUS

___ LAMOTRIGINE LAMOT

___ LEFLUNOMIDE METABOLITE LEFLU

REQUIRED

___ SALICYLATE

___ IMIPRAMINE + DESIPRAMINE RIMRPG

___ LEVETIRACETAM

RNTRP

___ PHENYTOIN (Dilantin)

DOSAGE

MPA

___ PENTOBARBITAL PENTO

CBAM

___ CARBAMAZEPINE

___ DIGOXIN

THEO
TCN

__ Peak __ Trough __ Random

TOBRAP, TOBRAT, TOBRAR

___ VALPROIC ACID
___ VANCOMYCIN

VPA

__ Peak __ Trough __ Random

GENTAP, GENTAT, GENTAR

___ VORICONAZOLE

VOR

DRUG SCREENING AND OVERDOSE

ADDRESS

___ DRUG SCREEN, URINE, STANDARD *

Suspected Drugs
STATE

CITY

ZIP

ALCOHOL SCREEN, SERUM OR PLASMA

TELEPHONE
PATIENT ADDRESS
CITY

STATE

ZIP

___ Ethanol, Methanol, Isopropanol, Acetone AS

___ Ethanol Only
ETOH
___ Methanol Only
MEOH

CARBON MONOXIDE (Whole Blood)

TELEPHONE

___ Arterial

ABCO

___ Venous

VCO

CHRONIC PAIN MANAGEMENT* (Indicate expected drugs)

Expected Drugs

SUBSCRIBER NAME
SUBSCRIBER ID. #

Premera Blue Cross

___ Acetaminophen
___ Amphetamines
___ Barbiturates
___ Benzodiazepine
___ Cannabinoids
___ Cocaine
___ Ethanol
___ Methadone
___ Opiates
___ Phencyclidine
___ Tricyclic Antidepressants

___ ETHYLENE GLYCOL, SERUM

UDRSS
UTYLQL
UAMTQL
UBRBQL
UBNZQL
UTHCQL
UCOCQL
UETHQL
UMDNQL
UOPIQL
UPCPQL
UTRIQL

EGLY

___ NICOTINE & COTININE, URINE

UNICOT

___ OXYCODONE, URINE, QUAL.

UOXCQL

___ SALICYLATE, URINE, QUAL.

UASAQ

___ TRICYCLIC ANTIDEPRESSANTS (SemiQuant.) TTRI

GROUP #
Regence

DSHS (attach current coupon)

___ Chronic Pain Drug Screen, Urine - Risk Level 1 UCPD1B

___ Chronic Pain Drug Screen, Urine - Risk Level 2 UCPD2B

___ Chronic Pain Drug Screen, Urine - Risk Level 3 UCPD3B

Medicare (answer required question below)

DRUG SCREEN CONFIRMATION, URINE

Is this either a hospital outpatient or inpatient?

___ Amphetamines*

___ Opioids*

Other Insurance Name/Address

___ DRUG SCREEN, URINE, COMPREHENSIVE*

Canary - CSO
Rev. 10/13

University of Washington Medical Center

1959 NE Pacific St, NW 220
Seattle, WA 98195
(206) 685-6066 Billing/Specimen Pick-up

___ MYCOPHENOLIC ACID

PM ___ CYCLOSPORINE by LCMS CSA

AM

Peak

REQUIRED

PROCESSED BY:

THERAPEUTIC DRUG LEVELS

REQUIRED
Urine

LOGGED IN BY:

When ordering tests for which Medicare reimbursement will be sought, physicians should only order tests which are medically necessary
for diagnosis or treatment of the patient. You should be aware that Medicare generally does not cover routine screening tests, and will
only pay for tests that are covered by the program and are reasonable and necessary to treat or diagnose the patient.

NPI #

ORDERING PHYSICIAN

Clear

1. Completely fill in left section. Tests in BOLD are available STAT.

2. Consult our Web site for test information, http://depts.washington.edu/labweb
3. Asterisk (*) - See back

D.O.B.

SPECIMEN

Print

UW LAB ACC. #

Golden Rod - Lab

Pink - SPS

White - Referring Lab

UAMPC
UOPIAC
UDRSCG

Other Tests

CMS MEDICAL NECESSITY INFORMATION

It is our policy to provide health care providers with the ability to order only those lab tests medically necessary for the individual patient and to ensure that the convenience of ordering standard
panels and custom profiles does not impact this ability. While we recognize the value of this convenience, indiscriminate use of panels and profiles can lead to ordering tests that are not
medically necessary. Therefore, all tests offered in our panels and profiles can be ordered individually as well. If a component test is not listed individually on the request form, it may be written
in the OTHER REQUESTS box. We encourage you to order individual tests or a less inclusive profile when not all of the tests included in the panel or profile are medically necessary for the
individual patient.

MEDICARE BILLING INFORMATION

edicare billing policy prevents us from submitting a Medicare claim for laboratory testing referred to us on hospital inpatients or hospital outpatients. For these samples,
M
we will bill the sending location.

URINE DRUG INFORMATION

1. Urine drug tests noted with an asterisk on the front side are available in a screening panel or they can be ordered individually.

Please check the desired individual drug(s) only under the DRUG SCREEN URINE, STANDARD header. Checking the header will order the entire panel.
Alternatively, you may write in the desired individual drug(s) in the OTHER TESTS box.
2. Urine drug tests noted with an asterisk on the front side are assayed using an immunochemical method. Positive immunochemical results can be confirmed by
chromatographic - mass spectrometric methodology for an additional charge. If confirmation is desired, please call the Toxicology lab at 206.744.3451 to request the
appropriate confirmation. Confirmation testing is not available STAT because it is referred to an outside laboratory.

CHRONIC PAIN MANAGEMENT

CHRONIC PAIN DRUG SCREEN, URINE - RISK LEVEL 1 (UCPD1A)

Moderate Risk
For patients at moderate risk for addiction (morphine equivalent dose < 120 mg/day, ORT score 4-7), evaluate for aberrant behavior (including early prescriptions and lost prescriptions). If
aberrant behavior is absent, then order as for low risk above. If present, then consider adding to the problem list and order testing as for high risk below.

CHRONIC PAIN DRUG SCREEN, URINE - RISK LEVEL 2 (UCPD2)

Low Risk
For patients at low risk for addiction (morphine equivalent dose < 120 mg/day, ORT score 0-3), yearly testing is adequate. Includes Urine Pain Drug Screen (UPAIN), a panel of
immunoassays for: Amphetamine, Methamphetamine, Barbiturates, Benzodiazepines, Cocaine, Cannabinoids/THC, Opiates, Oxycodone, Buprenorphine, and Methadone. When positive for
methamphetamine or cocaine, samples will automatically be sent for more specific testing. Based on the Expected Drugs listed, Lab Medicine may add a chromatographic-mass
spectro metric confirmatory assay for opioids (UOPIAC) for optimal patient care. UPAIN is performed daily, the additional testing including UOPIAC, at least twice per week. In some clinics,
this or a similar panel of tests may be performed on a point-of-care test device.

High Risk with no concern for Alcohol Abuse

For patients at high risk for addiction (morphine equivalent dose > 120 mg/day or ORT score > 8), more rigorous testing is recommended (2-4 times per year, and more for aberrant
behavior). Includes the UPAIN panel of immunoassays and UOPIAC, a confirmatory chromatographic-mass spectro metric assay that includes the opioids in the UPAIN panel (above), plus
fentanyl and meperidine.

CHRONIC PAIN DRUG SCREEN, URINE - RISK LEVEL 3 (UCPD3)

For help with what tests to order or with analytical interpretation of results, please consider consulting with the Laboratory Medicine Resident or Chemistry Fellow on call through the UW
Paging Operator (206-598-6190). For help with the use of drug testing results in individual patient care, please consider consulting with the doc-of-the-day at the UW Pain Center at
206-598-4282 (8AM-5PM on weekdays).

High Risk with concern for Alcohol Abuse

For patients at high risk for opioid abuse where a concern for heavy alcohol abuse is present, this panel includes UCPD2 plus an assay for alcohol. A negative test for urine ethanol does
not ensure abstinence.

DRUG SCREEN CONFIRMATION, URINE

AMPHETAMINES
Includes Amphetamine (MDA) and Methamphetamine (MDMA) (Ecstasy)
OPIOIDS

Includes 6-monoacetylmorphine, buprenorphine, codeine, fentanyl, norfentanyl, hydrocodone, hydromorphone, meperidine, normeperidine, methadone, morphine, oxycodone, oxymorphone,
propoxyphene.

DRUG SCREEN, URINE, COMPREHENSIVE

Includes Standard Urine Drug Screen, Urine Salicylate plus GC MS screen for additional drugs.

DRUG SCREEN, URINE, STANDARD

Includes Acetaminophen, Amphetamines, Barbiturates, Benzodiazepine, Cannabinoids, Cocaine, Ethanol, Methadone, Opiates, Phencyclidine, Tricyclic Antidepressants.