1. health and fitness
2. addiction

NEW CLIENT
REGISTRATION
Welcome to Ally Clinical Diagnostics
We appreciate your business. Please complete form and email to [email protected].
Date of Registration:______________/________ /________
Sales Rep:________________________________________
Telephone Number:_______________________________
Email:___________________________________________
Distributor:_______________________________________
Practice and Practitioner Information
(If there are multiple locations, the following information is needed for EACH location.)
Practice Name:____________________________________________
Office Hours:_________________________________________________
Street Address:____________________________________________
Pick-up Days:________________________________________________
City:_______________________ State:________ Zip:_____________
Preferred pick-up time:________________________________________
(Must be an hour window)
Phone:___________________________________________________
Fax:______________________________________________________
Contact Person:___________________________________________
Preferred Email:___________________________________________
Collector Name:___________________________________________
How would you like to
receive your results?
Portal
Collector Email:___________________________________________
Fax
Collector Telephone:_______________________________________
Provider Name: ________________________________________________________________NPI:______________________________________
Provider Name: ________________________________________________________________NPI:______________________________________
Provider Name: ________________________________________________________________NPI:______________________________________
Provider Name: ________________________________________________________________NPI:______________________________________
Additional providers require additional forms.
Practitioner Acknowledgement
I hereby acknowledge that Ally Clinical Diagnostics will perform drug testing for patients from my practice as directed
by my custom profile and by the individual patient Test Requisition Form.
Signature:______________________________________________
Signature:______________________________________________
Signature:______________________________________________
Signature:______________________________________________
Date:____________________________________________
Ally Clinical Diagnostics • 2099 Valley View Ln. • Dallas, Texas 75234 • AllyClinicalDiagnostics.com
Phone: 1-972-630-6850, (toll-free) 1-844-214-4444 • [email protected]
50185 04-06-2015 ALLY CLIENT REGISTRATION
STANDING TOXICOLOGY
CONFIRMATION ORDER
Standing order renewal date is Jan 15th 2016.
Drug Screen
ALL CLASSES (Full Comprehensive Panel)
* All drug classes can be tested by via a urine sample but only those that have an * next to them can ALSO be tested with a saliva sample.
Amphetamines*
Barbiturates
Benzodiazepines*
Buprenorphine*
Cannabinoid 50*
Carisoprodol
Cocaine*
Ethyl Alcohol
Ethyl Glucuronide
Ecstasy 500
Fentanyl
K2 ( Synth. Thc )
Methadone*
Methaqualone
Opiates*
Drug Confirmation Panel
Oxycodone*
PCP
Tramadol*
Cotinine
6-Mam
Tricyclics
Urine Creatinine
Oxidants
Urine Ph
Urine Specific Gravity
ALL CLASSES (Full Comprehensive Panel)
A Check mark on the check box alongside the Drug Class represents all drugs under the drug class. All drugs in the drug confirmation panel can be tested via urine or saliva samples
OPIATES/ANALGESICS
AMPHETAMINES/
STIMULANTS
HYDROCODONE
HYDROMORPHONE
AMPHETAMINE (P) (S)
OXYCODONE
METHAMPHETAMINE (P) (S)
OXYMORPHONE
RITALINIC ACID (P) (S)
MORPHINE
CODEINE
SSRI
FLUOXETINE (P)
CITALOPRAM (P)
PAROXETINE (P)
SERTRALINE (P)
PCP
METHADONE
TAPENTADOL
MEPERIDINE
METHADONE
NORMEPERIDINE
PCP (PHENCYCLIDINE) (IL)
EDDP (METHADONE METABOLITE)
NORHYDROCODONE
SUFENTANIL
FENTANYL
6-MAM (IL)
NORFENTANYL
BUPRENORPHINE
K2 (SYNTH. THC)
NORBUPRENORPHINE
SPICE CANNABINOID (IL)
5-PENTANOID AC ID METABOLITE (IL)
CANNABINOID 50
ALPHA-HYDROXYALPRAZOLAM (P)
7-AMINOCLONAZEPAM (P)
FENTANYL
BUPRENORPHINE
BENZODIAZEPINES
HYDROXY PENTYL METABOLITE (IL)
THC-COOH (IL)
FLURAZEPAM (P)
FLUNITRAZEPAM (P)
LORAZEPAM (P)
NORDIAZEPAM (P)
TEMAZEPAM (P)
ALPHA-HYDROXYMIDAZOLAM (P)
ALPRAZOLAM (P)
CLONAZEPAM (P)
DIAZEPAM (P)
TRICYCLICS
CARISOPRODOL (SOMA)
AMITRIPTYLINE (P)
IMIPRAMINE (P)
CARISOPRODOL
DESIPRAMINE (P)
MEPROBAMATE
MIDAZOLAM (P)
ZOLPIDEM (P)
ZOLPIDEM-PHENYL
CARBOXYLIC ACID (P)
NORTRIPTYLINE (P)
OPIOID ANTAGONISTS
PROTRIPTYLINE (P)
COCAINE
NALAXONE
BENZOYLECGONINE (S) (IL)
TRAMADOL
NALTREXONE
O-DESMETHYL-CIS-TRAMADOL
ECSTASY 500
ANTICONVULSANTS/
ANALGESICS
TRAMADOL
MDA (IL)
MDMA (IL)
COTININE
MDEA (IL)
COTININE
GABAPENTIN
Important to Note:
A symbol (P) besides the drug represents Psychiatric Panel
A Symbol (IL) besides the drug represents Illicit Drug Panel
A Symbol (S) besides the drug represents Stimulants Panel
I understand that I will have the ability to individually redefine this test profile on the test requisition form. I also understand that the lab
will confirm medication I prescribe as listed on each individual requisition form.
I wish to order solely from the individual Requisition Forms.
Physician Signature:____________________________
Physician Name (printed):_______________________
(Each provider needs their own standing order)
Date:___________________
PHYSICIAN/PRACTITIONER’S
ACKNOWLEDGMENT
FOR POCT ONLY (OPTIONAL)
Confirm all tests from my in-office testing.
Confirm only positives from my in-office testing.
I authorize Ally Clinical Diagnostics to perform testing on my patients from my practice as directed by
the individual Requisition Forms as well as my Customized Profile on file, if applicable.
I understand that it is my option to use a Predefined Custom Profile or select Specific Tests on the
Test Requisition Form. If Specific Tests are ordered and I do not indicate to run my Predefined
Custom Profile, only those specific drugs indicated on the Requisition Form will be tested. Individual
patient-specific tests can be added by checking both the Predefined Custom Profile box as well as
the Specific Testing requests.
I understand that it is my responsibility to determine the medical necessity of tests I have requested
for the treatment and/or diagnosis of my patients. I agree to provide diagnosis codes, defined to
the highest level of specificity, for each test that I order in order to confirm medical necessity and
to enable Ally Clinical Diagnostics to bill effectively on my patients’ behalf. Tests that are deemed
medically unnecessary may result in a denial of payment and/or penalties.
I further understand that according to Medicare, “Confirmation of drug screens is indicated when
the result of the drug screen is different than that suggested by the patient’s medical history, clinical
presentation, or patient’s own statement.”
I also understand that the Office of the Inspector General (OIG) has cautioned:
“Using a customized profile may result in the ordering of tests which are not covered,
reasonable or necessary”
“OIG takes the position that an individual who knowingly causes a false claim to be
submitted may be subject to sanctions or remedies available under civil, criminal,
and administrative law.”
CPT coding, based on AMA guidelines, is provided for your convenience. I understand that Ally
Clinical Diagnostics will be billing third parties for the tests I ordered using the CPT codes noted in
the Annual Notice to Physicians. In the event that Medicare, Medicaid, or other insurance providers
request documentation, I will provide signed written orders from the patients’ medical records to
the requesting party within 72 hours.
My Predefined Custom Panel will be valid for one year from the date of signature. My review and
reauthorization will be required after the expiration date. I understand I may request earlier changes
to my Predefined Custom Profile at any time. I have received copies of Ally Clinical Diagnostics’ Notices
to Physicians/Practitioners which includes Medicare’s National Limitation Amounts.
PHYSICIAN/PRACTITIONER’S
ACKNOWLEDGMENT
The Following Statements reflect the views, recommendations and guidelines outlined in the CMS
National Coverage Policy:
“ … Diagnostic tests may only be ordered by the physician who is treating the beneficiary, that is, the
physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who
uses the results in the management of the beneficiary’s specific medical problem.”
Urine is the best source for broad qualitative drugs of abuse testing because blood is insensitive for
common drugs such as psychotropic agents, opioids, and stimulants.
Point of care providers use chemical “spot tests” such as dip sticks, cassettes, and cups. This type of
screening is limited by the potential for false positives and cross reactivity.
Confirmatory testing should only be ordered and performed on a patient/drug specific basis within the
parameters outlined in this policy and documented in the patient record.
Qualitative drug testing must be documented in the medical record, must follow clinical guidelines and
validated risk assessment, stratification, and monitoring tools.
Prior to ordering a drug screen or confirmatory drug test the clinician should consider the following
patient specific elements: history, current treatment plan, risk potential for abuse, diversion of
controlled medications.
Covered indications: qualitative drug testing-Medicare considers qualitative drug testing reasonable
and necessary for the symptomatic patient suspected of multi drug ingestion, unexplained coma,
unexplained mental status, severe or unexplained cardiovascular instability, unexplained metabolic
or respiratory acidosis, seizures, to provide antagonist to specific drug.
A. Testing neonates suspected of prenatal drug exposure
B. Monitoring patient adherence and compliance during active treatment for substance abuse
or dependence
C. Chronic pain management testing protocols for chronic opioid therapy (COT)
Base-line testing: For evaluation of patients when they seek treatment involving controlled medication
to identify the following situations:
A. P
resence of illicit substances prior to initiating treatment involving controlled medications
and
B. Presence of illicit drugs
PHYSICIAN/PRACTITIONER’S
ACKNOWLEDGMENT
Periodic testing: To monitor treatment plan compliance with a validated risk assessment, stratification,
and monitoring protocol to document the following risk potential:
A. Abuse and diversion of controlled medications
B. Abuse of illicit drug(s) not prescribed as part of the treatment plan
The frequency of drug testing should be based in part on the assessed risk that the patient will engage
in medication-aberrant behavior (or illicit drug use behavior.) Patients assessed at a higher risk for
medication misuse and illicit drug require more frequent testing than chronic pain patients assessed at a
lower risk. In the absence of specific symptoms of medication aberrant behavior or misuse, qualitative drug
testing is only reasonable and necessary when titrated to patient risk potential.
Patients with the following behaviors may require more testing:
A. History of aberrant drug related behaviors
B. Psychiatric co-morbidities
C. History of substance abuse
Target Testing – to identify patients with the following suspicious non-compliance behaviors:
A. Documented aberrant drug related or change in behavioral pattern
B. Illicit drug use, or
C. Use of prescription drugs not included in the current treatment plan
Frequency of Drug Testing Based on Validated Risk Assessment:
A. Low Risk every 6 months
B. Moderate Risk every 3 months
C. High Risk regularly, but not necessarily every drug at every visit
Confirmatory and/or Quantitative Drug Testing: reasonable and necessary when the results of a
qualitative screen are:
A. Presumptive positive drug(s) on a drug screen
B. Presumptive positive for stimulant (amp), barbiturate and benzodiazepine class of drugs
C. N
egative screen, and the negative finding is inconsistent with the patient’s medical history
or current documented chronic pain medication list
D. When the coverage criteria of this policy are med AND there is not qualitative test available
PHYSICIAN/PRACTITIONER’S
ACKNOWLEDGMENT
Limitations of Coverage:
In all cases, drugs or drug classes for which testing is performed, should reflect only those likely to be
present, based on the patient’s medical history, current clinical presentation, and illicit drugs that are
in common use. In other words, it is NOT medically necessary or reasonable to routinely test for
substances (licit or illicit), which are not used in the patient treatment population or, in the instance of
illicit drugs, in the community at large. Drugs for which specimens are being tested must be indicated
by the referring provider in a written order.
Focused drugs screens, most commonly for illicit drug use may be more useful for immediate or
temporary clinical decision making to support continuation or discontinuation of a treatment plan.
In addition routine confirmation (quantitate) of drug screens with negative results is not covered by Medicare. Confirmatory testing is covered for a negative drug/drug class screen when the negative finding is
inconsistent with the patient’s medical history or current documented chronic pain
medication list.
Non-Covered: Routine nonspecific drug screening; test for the same drug(s) using a blood and a urine
specimen at the same time; Drug screening for medico-legal purposes; unvalidated test sources such as
saliva, oral fluids, and hair.
Physicians are to select the most appropriate diagnosis code. Labs are not to pre-populate requisition
forms with diagnosis codes.
The physician must use a CLIA-waived point-of-care test or CLIA-approved test (FDA cleared/approved) that
uses a devise to measure pH, specific gravity and temperature. Results of the drug test must be read
according to the manufacturer’s instructions.
Patient drug testing must be conducted and reviewed prior to the initial issuance or dispensing of a
controlled substance prescription, and thereafter on a random basis at least twice a year or when
requested by the treating physician.
Physicians should exercise caution when relying on customized test panels and standing orders and
ensure that medical necessity exists for the testing of all drugs/drug classes within the panel. Multiple
ICO-9/1CD-10 codes should be used to justify testing of multiple drug classes.
Any questions regarding our Customer Service, please call 1-972-630-6850, or (toll-free) 1-844-214-4444.
Practitioner’s Signature:______________________________________________________________ Date_______________
Practitioner’s Name:_____________________________________________________________________________________