Buprenorphine 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. Buprenorphine Screen, Urine | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
BUPUR/SUMMA
Test Workstation :
Summa
Specimen Type:
Urine-Random
Tube Type:
Urine container
Collection Volume:
3.0 mL
Storage:
Refrigerated
Availability:
7 days a week on day shift and second shift only
Methodology:
Immunoassay
Lab/Phone:
330-543-8418
TAT:
1-2 days
CPT Code:
80307
Synonyms:
Suboxone
