POC EREQ

Account Number

Account Name

First Name

Middle Initial

Last Name

DOB

Sex

Race

Ethnicity

Phone Number

Social Security Number

Driver License/ID Number

U.S. Address

Address 2

City

State

Zip

Client Bill Third Party Insurance

Insurance

Insurance not listed

Policy Number

Group Number

Provider

Provider not listed

DX Codes: (select all that apply)

Sample Collection Date

Amphetamine 1000 ng/mL

Barbiturates 300 ng/mL

Benzodiazepines 300 ng/mL

Buprenorphine 10 ng/mL

Cocaine 300 ng/mL

MDMA 500 ng/mL

Methadone 300 ng/mL

Methamphetamine 1000 ng/mL

Morphine 300 ng/mL

Oxycodone 100 ng/mL

PCP 25 ng/mL

THC 50 ng/mL

Tricyclic Anti-Depressants 1000 ng/mL

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