Welcome to LabSolutions, LLC

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1 Welcome to LabSolutions, LLC Upon requesting our services, we will supply Specimen Transport Cups, Bio Bags, UPS Lab Paks, UPS Shipping Labels, Test Requisition Forms, and Patient Acknowledgement Forms. Additional supplies are available at your request. Fax an Order Form to LabSolutions at: (404) When collecting a sample for testing, simply select from the 32 compounds listed on your Test Requisition Form. Place the Specimen Transport Cup in the provided UPS Bio Bag and slide the completed Test Requisition Form in the separate Bio Bag pocket. After attaching the UPS Shipping Label, call UPS for a pickup when a minimum of five Bio Bags are ready for transport. Upon arrival, the specimen sample will be analyzed according to the Test Requisition Form using LC/MS/MS technology. No prescreening will be used in our Laboratory; ALL specimens are tested with research quality equipment, giving you the most accurate urinalysis results available. Per your preference, Custom Test Results will be available via secure web-reporting or auto-fax within 3-5 business days of sample receipt. As part of LabSolutions s service, we will provide direct billing to your patient s insurance carrier(s). Thank you for choosing LabSolutions.

2 Directors HOW YOU ENGAGE OUR SERVICES Just Contact us: LabSolutions, LLC 548 Ponce de Leon Avenue NE Atlanta, GA Phone: Fax: Directory of Laboratory Personnel Suneal Jannapurdy, MD Corinne R. Fantz, PHD Medical Director Scientific Director Operations Minal Patel Chief Operations Officer Technical Support Angela Baxter Toxicology Department Manager LabSolutions 548 Ponce de Leon Avenue NE Atlanta, GA Phone: Fax:

3 Corinne R. Fantz, Ph.D., DABCC, FACB Clinical Consultant, Lab Solutions, LLC Corinne R. Fantz, Ph.D., DABCC, FACB is a clinical toxicology consultant for Lab Solutions. Her technical knowledge is a huge asset for our clients. Dr. Fantz is available to answer questions for Lab Solutions clients pertaining to toxicology test results and drug metabolism. Dr. Fantz is nationally and internationally recognized as a leader in laboratory quality, test utilization and patient safety having served on a CDC s Lab Medicine Best Practices (LMBP) Expert Panel and the International Federation of Clinical Chemistry (IFCC) Task Force on Patient Outcomes. Dr. Fantz received her Ph.D. in biochemistry from the University of South Carolina and completed a postdoctoral fellowship in clinical chemistry at Washington University in St. Louis. She is a past president and Diplomat of the American Board of Clinical Chemistry and a fellow of the National Academy of Clinical Biochemistry. Prior to consulting for Lab Solutions, she was Associate Professor of Pathology in the Department of Pathology and Laboratory Medicine and Director of Quality for Clinical Pathology at Emory University Hospital in Atlanta, GA. Dr. Fantz was responsible for the core laboratories, which performed more than 6 million tests per year including comprehensive toxicological screening and therapeutic drug monitoring. She has trained more than 100 residents, fellows and medical technologist trainees in laboratory medicine and published more than 50 peer-reviewed articles, book chapters and abstracts. List of selected publications and abstracts: Pomerleau AC, Fantz CR, Gooden C, Morgan BW Dermal exposure to a compounded pain cream resulting in severely elevated clonidine concentration In Press Journal of Medical Toxicology 2013 Baumann NA, Fantz CR, Hines JM, Hendrix BK, Ness KM, Algeciras-Schimnich A. Thyroxine (T4) Immunoassays to LC-MS/MS in Serum from Nonpregnant and Pregnant Females. International Federation of Clinical Chemistry, Milan, Italy 2013 Rhea JM, Snyder ML, Winkler AM, Abou-Diwan C, Fantz CR, Ritchie JC, Szlam F, Tanaka KA, Molinaro RJ. Development of a fast and simple liquid chromatography-tandem mass spectrometry method for the quantitation of argatroban in patient plasma samples. J Chromatogr B Analyt Technol Biomed Life Sci Mar 3. Mathew G, Kho A, Dexter P, Bloodworth N, Fantz C, Spell N, Laborde DV. Concept and Development of a Discharge Alert Filter for Abnormal Laboratory Values Coupled With Computerized Provider Order Entry: A Tool for Quality Improvement and Hospital Risk Management. J Patient Saf Apr 26.

4 Phone: Fax: Supply Order Form PLEASE ALLOW 2-5 DAYS FOR DELIVERY Date of Request: Clinic Name and Address: Requestor s Name: Please check boxes for all supplies needed: Specimen Cups: Quantity of UPS Preprinted Labels: Quantity of UPS Laboratory Shipping Bags: Quantity of Test Requisition Forms: Quantity of Patient Acknowledgement Forms: Quantity of On-site Drug Screen Tests/Cups: Quantity of UPS Boxes: Quantity of Bio Hazard Bags: Quantity of

5 Patient Acknowledgement Your physician and/or healthcare provider has requested that a sample of your urine be tested by LabSolutions, LLC to monitor the levels of medication in your system. LabSolutions, LLC provides a specialized Prescription and Substance Monitoring Program that will help your physician or healthcare provider to: Prevent dangerous drug to drug interactions Monitor compliance with your treatment plan Reduce the risk of adverse side effects from the medication you are prescribed Identify the most appropriate treatment plan for your individual needs Please understand the following: LabSolutions, LLC will report the results of the testing to your physician or healthcare provider LabSolutions, LLC will maintain the confidentiality of the test results Results will not be released by LabSolutions, LLC to any other medical professionals or other parties without the advance written consent or otherwise permitted by law LabSolutions, LLC will bill your insurance or other healthcare coverage for this testing. LabSolutions, LLC will accept these fees, as determined by your coverage plan for the services. LabSolutions, LLC will generate a statement for any remaining balance. You are responsible for paying LabSolutions, LLC any co-pays, deductibles or non covered services as dictated by your insurance plan. If you have any questions or concerns about this, please contact LabSolutions, LLC at LabSolutions, LLC welcomes the opportunity to discuss various payment options with you. I have reviewed this form and have had an opportunity to have any questions answered that I have regarding this form and my rights to privacy. Patient Signature Patient Printed Name Date

6 tive: 6/11/2013 URINE COLLECTION INSTRUCTIONS For Collection of Patient Urine Specimen follow the steps below: Step 1: Write patient s name rst and last) and DOB directly on the requisition sticker located in the upper right hand corner of the requisition form. Step 2: Place the labeled sticker on the urine collection or screening cup. Step 3: Provide the cup to the patient ask patient (or family member/ care giver) to con rm that the information on the cup is correct. Step 4: Fill out remainder of requisition form (SS#, DOB, medications, and additional testing insurance, etc). Step 5: If using a screening cup for collection, record patient results from the screening cup on the requisition form. Make sure to read cup within allotted window as instructed by cup manufacturer. Step 6: Maintain the pink copy of the requisition form for patient chart. Place the other two copies of the form in the back pocket of the specimen bag. Step 7: Refer to the document in the LabSource welcome packet titled, How to Ship Urine Specimen, for proper instructions for the shipment of specimens to LabSolutions LLC. LabSolutions 548 Ponce de Leon Avenue NE Atlanta, GA Phone: Fax:

7 IMPORTANT INFORMATION FOR SCREENING CUP USERS This is the best sample level for testing. Please have the patient ll the cup to this level when possible. This is more sample than is necessary for testing. Please try to send less than this when possible. NOTICE: UPS will discard your samples if any leaking occurs. Please insure that the cups are fastened tightly and the sample bags and UPS bags are completely sealed. How to Interpret Screening Cup Results: Although this line is faint, the line is still present and therefore would be classi ed as negative reading. This line has not appeared; therefore this would be classi ed as a positive reading. SCREENING CUP INFORMATION According to the cup insert, the positive or negativ e distinction is based upon presence or absence of a line. It is not based on line intensity. Any trace of a line should render that test negative. LabSolutions 548 Ponce de Leon Avenue NE Atlanta, GA Phone: Fax:

8 HOW TO SHIP URINE SPECIMEN: Step 1: Requisition Form Fill out requisition form Step 2: Collection Cup OR Screening Cup Collect patient specimen and place sticker identi er on cup. Step 3: Biohazard Bag Place specimen in biohazard bag and Requisition form in back pocket Step 4: UPS Shipping Bag Place 1-10 specimens in UPS shipping bag. Step 5: UPS Shipping Box Place bag inside UPS shipping box and seal. Step 6: UPS Shipping Label Place label on UPS shipping box. To order supplie l out and fax the Supply Order Form provided in your LabSource Welcome Packet. *URINE COLLECTION AND/OR SCREENING CUPS WILL BE DISTRIBUTED BASED ON EACH CLINIC S SPECIFIED NEEDS* LabSolutions 548 Ponce de Leon Avenue NE Atlanta, GA Phone: Fax:

9 Please select the urine testing panel or individual tests you are requesting from the options below. Comprehensive Urine Drug Analysis (UDA) Panel By selecting the Comprehensive UDA Panel, you are requesting testing for all of the following compounds. Individual tests may be requested by checking the boxes below. LC-MS/MS: AMPHETAMINES amphetamine, methamphetamine, methylphenidate, phentermine ANTICONVULSANTS gabapentin, pregabalin BENZODIAZEPINES alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam lorazepam, midazolam, oxazepam, temazepam, triazolam ILLICIT DRUGS bath salts (4-fluoromethcathinone, MDPV, mephedrone, methylone, methedrone), cocaine, MDMA, PCP MUSCLE RELAXANTS carisoprodol, cyclobenzaprine, meprobamate OPIOIDS buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, pentazocine, propoxyphene, tapentadol, tramadol EIA: (Enzyme Immunoassay) BARBITURATES ETHANOL ETHYL GLUCURONIDE HEROIN METABOLITE SYNTHETIC CANNIBINOIDS THC VALIDITY TESTING ph, specific gravity, creatinine Testing for Tricyclic Antidepressants is available upon request. OFFICE USE ONLY Reviewed and processed by: Sign Date PHYSICIAN S STA NDING ORDER FORM PRACTICE INFORMATION PRACTICE NAME: ADDRESS: City State Zip Contact Phone ( ) - PHYSICIAN AUTHORIZATION This standing order represents my determination that it is both medically necessary and a matter of the prudent practice of medicine to run the selected urine drug testing. I authorize LabSource, LLC to perform urine drug analysis on patients from my organization as indicated on this form. In addition, I hereby authorize and instruct LabSource, LLC to run the selected testing on all samples sent to LabSource, LLC. I understand that this standing order will remain in effect until an updated form is completed. I also understand that I may change this order, on a case -by-case basis, by making my testing preferences clear on the laboratory service requisition form. Physician s Name Physician s NPI# Signature Physician s Name Specialty Physician s License# Date Specialty Physician s NPI# Physician s License # Signature Date Please circle the manner in which your office wouldprefer to receive UDA results from Labsource, LLC: Web-portal User ID Password Fax ( ) - Auto Fax ( ) - Please note: LabSource testing panels are under continual modification and improvement to meet the challenges and risks associated with the treatment of pain /behavioral/addiction management patients.

10 COMPREHENSIVE TOXICOLOGY PANEL Drug Class Compounds/Metabolites Detected Detection Window Prescription Brand Name/Other AMPHETAMINES/STIMULANTS Amphetamine amphetamine 3-5 days Adderall Adderall XR Dexedrine Dextroamphetamine Dextrostat Methamphetamine methamphetamine, amphetamine 3-5 days Desoxyn Gradumet Vicks Inhaler Methylphenidate** methylphenidate 1-2 days Concerta Daytrana Metadate Methylin Ritalin Phentermine** phentermine 3-5 days Apidex-P Ionamin Pro-Fast ANTICONVULSANTS Gabapentin** gabapentin 1-2 days Neurontin Pregabalin** pregabalin 1-2 days Lyrica BENZODIAZEPINES Alprazolam alpha-hydroxyalprazolam 2-4 days Alprazolam Intensol Niravam Xanax Xanax XR Chlordiazepoxide nordiazepam, oxazepam 2-4 days Librium Clonazepam 7-aminoclonazepam 2-4 days Klonopin Clorazepate nordiazepam, oxazepam 2-4 days Tranxene Diazepam nordiazepam, oxazepam, temazepam 2-7 days Diastat Diazepam Intensol Dizac Valium Lorazepam lorazepam 5-7 days Ativan Lorazepam Intensol Midazolam alpha-hydroxymidazolam 1-2 days Versed Oxazepam oxazepam 2-7 days Serax Temazepam temazepam, oxazepam 1-4 days Restoril Triazolam alpha-hydroxytriazolam 1-2 days Halcion MUSCLE RELAXANTS Carisoprodol carisoprodol, meprobamate 1 day Soma Cyclobenzaprine** cyclobenzaprine 3-8 days Flexeril Fedmid Amrix Meprobamate meprobamate 2-3 days Equanil Miltown OPIATES/OPIOIDS Buprenorphine buprenorphine, norbuprenorphine Up to 14 days Buprenex Suboxone Subutex Codeine codeine, morphine, hydrocodone (minor 2-3 days Fioricet w/codeine Fiorinal Tylenol w/codeine #2, #3, #4 metabolite) Fentanyl fentanyl, norfentanyl 1-3 days Actiq Duragesic Fentora Ionsys Sublimaze Hydrocodone hydrocodone, hydromorphone, norhydrocodone 2-3 days Hydrocet Lorcet-HD Lorcet Plus Lortab Norco Panacet Panasal T-Gesic Vicodin Vicodin ES Vicodin HP Vicoprofen Hydromorphone hydromorphone 2-3 days Dilaudid Dilaudid-HP Palladone Meperidine meperidine, normeperidine hours Demerol Mapergan Methadone methadone, EDDP up to 14 days Dolophine Diskets Methadose Methadone HCl Intensol Morphine morphine, hydromorphone (minor metabolite) 2-3 days Astramorph Avinza Duramorph DepoDur Embedda Infumorph Kadian MS Contin MSIR Oramorph SR Paregoric RMS Roxanol Oxycodone oxycodone, oxymorphone, noroxycodone 2-3 days Endocet ETH-Oxydose M-Oxy OxyContin Oxydose OxyFAST OxyIR Percocet Percolone Percodan Roxicodone Roxicodone Intensol Roxicet Roxilox Roxiprine Tylox Oxymorphone oxymorphone 2-3 days Numorphan Opana Opana ER Pentazocine pentazocine 1-2 days Talacen Talwin Talwin NX Propoxyphene propoxyphene, norpropoxyphene up to 7 days Darvocet Darvon Darvon-N Propacet Wygesic Tapentadol tapentadol 2-3 days Nucynta Tramadol tramadol, desmethyltramadol 2-4 days Ultram Ultram ER ILLICITS Bath Salts 3,4-methylenedioxypyrovalerone (MDPV), 4- fluoromethcathinone (4-FMC), mephedrone, methedrone, methylone 2-5 days Cloud 9, White Lightning, Ivory Wave, others Cocaine benzoylecgonine 1-2 days Methylenedioxymethamphetamine MDMA 2-5 days Ecstacy (MDMA) Phencyclidine (PCP) PCP up to 21 days Angel Dust THC, Cannabinoids** Δ-9-carboxytetrahydrocannibinol up to 30 days Marinol Dronabinol **Astericks indicate drugs recently added to the LabSource confirmatory testing menu. Call for availability. DRUG SCREENS (IMMUNOASSAY) Amphetamines Ethyl glucuronide Barbiturates Heroin Metabolite (6-MAM) SPECIMEN VALIDITY (ADULTERATION) TESTING Benzodiazepines MDMA Creatinine Buprenorphine Methadone Specific Gravity Cocaine metabolite Opiates ph Cannabinoids, THC Oxycodone Cannabinoids, Synthetic (K2) PCP Cocaine metabolite Propoxyphene Ethanol Tricyclic Antideppressants

11 CLIA #: 42D Client: CLINIC TEST Client #: 54 Chart #: A Provider: TEST, PHYSICIAN DR Prescribed Medications: Patient: DOE, JOHN DOB: 01/01/1960 Gender: M Specimen Type: URINE Adderall (Amphetamine) Ativan (Lorazepam) Oxycodone 545 North Pleasantburg Dr. Suite 102 Greenville, SC Phone: (864) Fax: (864) Director: Marion Snyder, Ph.D., DABCC Lab Acc#: Collected: 04/24/13 Received: 04/24/13 09:06 Reported: 04/24/13 09:15 CONFIRMATION RESULTS SUMMARY PRESCRIBED: NOT-PRESCRIBED: Drug / Metabolite Result Interpretation Drug / Metabolite Result Interpretation A mphetamine INCONSISTENT alpha-hydroxyalprazolam POSITIVE INCONSISTENT Lorazepam POSITIVE CONSISTENT *THC-Delta-9-COOH POSITIVE INCONSISTENT Oxycodone POSITIVE CONSISTENT Methylone POSITIVE INCONSISTENT Oxymorphone POSITIVE CONSISTENT N oroxycodone POSITIVE CONSISTENT SPECIMEN VALIDITY TESTING IMMUNOASSAY SCREEN REPORT TEST RESULTS FLAG EXPECTED RESULTS DRUG RESULTS C reatinine 225 NORMAL THC POSITIVE p H 7.0 NORMAL 4-9 Barbiturates S pecific Gravity NORMAL Ethanol Amphetamines Cocaine Metabolite PCP Oxycodone POSITIVE MDMA 6MAM Benzodiazepines POSITIVE Opiates Buprenorphine Ethyl Glucuronide Synthetic Cannab (K2) POSITIVE Test Screen AMPHETAMINES mphetamine CONFIRMATION RESULTS Results Cutoff Conc. A 50 ng/ml M ethamphetamine 100 ng/ml BENZODIAZEPINES alpha-hydroxyalprazolam POSITIVE 50 ng/ml 752 ng/ml 7-AminoClonazepam 50 ng/ml Lorazepam POSITIVE 100 ng/ml >800 ng/ml N ordiazepam 100 ng/ml O xazepam 100 ng/ml T emazepam 100 ng/ml alpha-hydroxymidazolam 50 ng/ml alpha-hydroxytriazolam 100 ng/ml OPIATES/OPIOIDS C odeine 50 ng/ml M orphine 50 ng/ml H ydrocodone 50 ng/ml H ydromorphone 50 ng/ml N orhydrocodone 50 ng/ml O xycodone POSITIVE 50 ng/ml 245 ng/ml O xymorphone POSITIVE 50 ng/ml 112 ng/ml The results given are for clinical diagnostic purposes only. LABSOURCE, LLC. (864) Page 1

12 Client: CLINIC TEST Client #: 54 Chart #: A Provider: TEST, PHYSICIAN DR Patient: DOE, JOHN DOB: 01/01/1960 Gender: M Specimen Type: URINE Noroxycodone POSITIVE 50 ng/ml 553 ng/ml SYNTHETIC OPIOIDS Buprenorphine 5 ng/ml Norbuprenorphine 10 ng/ml Fentanyl 2.5 ng/ml Norfentanyl 2.5 ng/ml Methadone 50 ng/ml EDDP 50 ng/ml Meperidine 50 ng/ml Normeperidine 50 ng/ml Tramadol 50 ng/ml O-desmethyl-Tramadol 50 ng/ml Pentazocine 10 ng/ml Propoxyphene 50 ng/ml Tapentadol 10 ng/ml TRANQUILIZERS Meprobamate 50 ng/ml Carisoprodol 50 ng/ml ILLICITS Benzoylecgonine (Cocaine) 50 ng/ml Phencyclidine (PCP) 10 ng/ml *THC-Delta-9-COOH POSITIVE 15 ng/ml 77 ng/ml MDMA (Ecstasy) 50 ng/ml BATH SALTS MDPV 50 ng/ml Mephedrone 50 ng/ml 4-Fluoromethcathinone 50 ng/ml Methylone POSITIVE 50 ng/ml 125 ng/ml Methedrone 50 ng/ml ANTICONVULSANT Gabapentin 998 Lab Acc#: Collected: 04/24/13 Received: 04/24/13 09:06 Reported: 04/24/13 09:15 The results given are for clinical diagnostic purposes only. LABSOURCE, LLC. (864) Page 2

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