Targeted Opioid Screen Urine
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Targeted Opioid Screen Urine | |
| 2. | |
| 3. | |
| 4. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
TOSUR
Test Workstation :
Mayo
Specimen Type:
Urine
Tube Type:
Urine container
Collection Volume:
1.0 mL
Minimum Volume:
0.5 mL
Cause for Rejection:
Gross hemolysis, Gross icterus
Storage:
Refrigerated
Availability:
Sent to Reference Laboratory
Methodology:
Liquid Chromatography-Tandem Mass Spectrometry, High Resolution Accurate Mass (LC-MS/MS HRAM)
Special Instructions:
Please list prescribed opioids.
Lab/Phone:
330-543-8418
TAT:
2-4 days
Additional Info:
Reference Interval: Not Detected
CPT Code:
80364, G0481 (if appropriate)
Panel Includes:
Codeine, Codeine-6-beta-glucuronide, Morphine, Morphine-6-beta-glucuronide, 6-monacetylmorphine, Hydrocodone, Norhydrocodone, Dihydrocodeine, Hydromorphone, Hydromorphone-3-beta-glucuronide, Oxycodone, Noroxycodone, Oxymorphone, Oxymorphone-3-beta-glucuronide, Noroxymorphone, Fentanyl, Norfentanyl, Meperidine, Normeperidine, Naloxone, Naloxone-3-beta-glucuronide, Methadone, EDDP, Propoxyphene, Norpropoxyphene, Tramadol, O-desmethyltramadol, Tapentadol, N-desmethyltapentadol, Tapentadol-beta-glucuronide,Buprenorphine, Norbuprenorphine, and Norbuprenorphine glucuronide
