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 LabSolu-tions at: (404)228-5027.

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 complet-ed 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 accu-rate 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 insur-ance carrier(s).

Thank you for choosing LabSolutions.

Welcome to LabSolutions, LLC

LabSolutions, LLC

Phone: 404 228 5027

HOW YOU ENGAGE OUR SERVICES

Medical DirectorScientific Director

Operations

Chief Operations Officer

Technical Support

Angela Baxter Toxicology Department Manager

Directors

Directory of Laboratory Personnel

Fax: 404 343 0788

Just Contact us:

LabSolutions • 548 Ponce de Leon Avenue NE Atlanta, GA 30308 • Phone: 404 228 5027 • Fax: 404 343 0788

548 Ponce de Leon Avenue NEAtlanta, GA 30308

Suneal Jannapurdy , MDCorinne R. Fantz, PHD

Minal Patel

Corinne R. Fantz, Ph.D., DABCC, FACBClinical 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 national-ly 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. 2012 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. 2012 Apr 26.

Phone: 404-228-5027Fax: 404-343-0788

Supply Order Form

Date of Request: ___________________________________________

Clinic Name and Address:____________________________________

_________________________________________________________

Requestor’s Name: _________________________________________

Please check boxes for all supplies needed:

UPS Laboratory Shipping Bags: Quantity of _________

UPS Preprinted Labels: 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 _____

Specimen Cups: Quantity of _________

PLEASE ALLOW 2-5 DAYS FOR DELIVERY

Patient Acknowledgement

__________________________________________

Patient Signature__________________________________________Patient Printed Name__________________________________________

Date

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, deduct-ibles or non covered services as dictated by your insurance plan.

If you have any questions or concerns about this, please contact LabSolutions, LLC at 864-312-6930. LabSolu-tions, 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.

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 30308 • Phone: 404 228 5027 • Fax: 404 343 0788

IMPORTANT INFORMATION FOR SCREENING CUP USERS

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:

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.

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.”

This line has not appeared; therefore this would be classi ed as a positive reading.

Although this line is faint, the line is still present and therefore would be classi ed as negative reading.

LabSolutions • 548 Ponce de Leon Avenue NE Atlanta, GA 30308 • Phone: 404 228 5027 • Fax: 404 343 0788

HOW TO SHIP URINE SPECIMEN:

*URINE COLLECTION AND/OR SCREENING CUPS WILL BE DISTRIBUTED BASED ON EACH CLINIC’S SPECIFIED NEEDS*

Step 2: Collection Cup OR Screening Cup Collect patient specimen and place sticker identi er on cup.

Step 1: Requisition Form Fill out requisition form

Step 3: Biohazard Bag

Place specimen in biohazard bag and Requisition form in back pocket

To order supplie l out and fax the “Supply Order Form”

provided in your LabSource Welcome Packet.

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. Pl

Step 6: UPS Shipping Label Place label on UPS shipping box.

LabSolutions • 548 Ponce de Leon Avenue NE Atlanta, GA 30308 • Phone: 404 228 5027 • Fax: 404 343 0788

PHYSICIAN’S STA NDING ORDER FORM � Please select the urine testing panel or

individual tests you are requesting from the options below.

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-�uoromethcathinone, 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, speci�c gravity, creatinine

Testing for Tricyclic Antidepressants is available upon request.

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 e�ect 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 Specialty Physician’s NPI# Physician’s License# Signature Date

Physician’s Name Specialty Physician’s NPI# Physician’s License # Signature Date

Please note: LabSource testing panels are under continual modi�cation and improvement to meet the challenges and risks associated with the treatment of pain /behavioral/addiction management patients.

PRACTICE INFORMATION PRACTICE NAME: _________________________________________

ADDRESS: ______________________________________________

City _____________________State _______________Zip________

Contact ________________________________________________

Phone (_______) _________-_____________

Please circle the manner in which your o�ce would prefer to receive UDA results from Labsource, LLC:

Web-portal User ID _____________________

Password ___________________

Fax ( _______ )________-__________

Auto Fax ( _______ )________-__________

� Comprehensive Urine Drug Analysis (UDA) Panel

OFFICE USE ONLY Reviewed and processed by: Sign___________________Date_____________

COMPREHENSIVE TOXICOLOGY PANEL

Drug Class Compounds/Metabolites Detected Detection Window Prescription Brand Name/OtherAMPHETAMINES/STIMULANTSAmphetamine amphetamine 3-5 days Adderall® Adderall®XR Dexedrine® Dextroamphetamine® Dextrostat®

Methamphetamine methamphetamine, amphetamine 3-5 days Desoxyn® Gradumet® Vicks InhalerMethylphenidate** methylphenidate 1-2 days Concerta® Daytrana® Metadate® Methylin® Ritalin®Phentermine** phentermine 3-5 days Apidex-P® Ionamin® Pro-Fast®ANTICONVULSANTSGabapentin** gabapentin 1-2 days Neurontin®Pregabalin** pregabalin 1-2 days Lyrica®BENZODIAZEPINESAlprazolam alpha-hydroxyalprazolam 2-4 days Alprazolam® Intensol® Niravam® Xanax® Xanax®XRChlordiazepoxide 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 RELAXANTSCarisoprodol carisoprodol, meprobamate 1 day Soma®Cyclobenzaprine** cyclobenzaprine 3-8 days Flexeril® Fedmid® Amrix®Meprobamate meprobamate 2-3 days Equanil® Miltown®OPIATES/OPIOIDSBuprenorphine buprenorphine, norbuprenorphine Up to 14 days Buprenex® Suboxone® Subutex®Codeine codeine, morphine, hydrocodone (minor

metabolite)2-3 days Fioricet® w/codeine Fiorinal® Tylenol® w/codeine #2, #3, #4

Fentanyl fentanyl, norfentanyl 1-3 days Actiq®Duragesic® Fentora® Ionsys® Sublimaze®Hydrocodone hydrocodone, hydromorphone,

norhydrocodone2-3 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 24-48 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®ILLICITSBath Salts 3,4-methylenedioxypyrovalerone (MDPV), 4-

�uoromethcathinone (4-FMC), mephedrone, methedrone, methylone

2-5 days Cloud 9, White Lightning, Ivory Wave, others

Cocaine benzoylecgonine 1-2 daysMethylenedioxymethamphetamine (MDMA)

MDMA 2-5 days Ecstacy

Phencyclidine (PCP) PCP up to 21 days Angel DustTHC, Cannabinoids** Δ-9-carboxytetrahydrocannibinol up to 30 days Marinol® Dronabinol®

Amphetamines Ethyl glucuronideBarbiturates Heroin Metabolite (6-MAM) SPECIMEN VALIDITY (ADULTERATION) TESTINGBenzodiazepines MDMA CreatinineBuprenorphine Methadone Speci�c GravityCocaine metabolite Opiates pHCannabinoids, THC OxycodoneCannabinoids, Synthetic (K2) PCPCocaine metabolite PropoxypheneEthanol Tricyclic Antideppressants

DRUG SCREENS (IMMUNOASSAY)

**Astericks indicate drugs recently added to the LabSource con�rmatory testing menu. Call for availability.

545 North Pleasantburg Dr. Suite 102Greenville, SC 29607Phone: (864)312-6930Fax: (864)312-6927Director: Marion Snyder, Ph.D., DABCCCLIA #: 42D2043208

Client: CLINIC TESTClient #: 54Chart #: A1211130074Provider: TEST, PHYSICIAN DR

Patient: DOE, JOHNDOB: 01/01/1960Gender: MSpecimen Type: URINE

Lab Acc#: 1304240019Collected: 04/24/13Received: 04/24/13 09:06Reported: 04/24/13 09:15

Prescribed Medications: Adderall (Amphetamine)Ativan (Lorazepam)Oxycodone

CONFIRMATION RESULTS SUMMARYPRESCRIBED: NOT-PRESCRIBED:

Drug / Metabolite Result Interpretation Drug / Metabolite Result Interpretation detceteD toN enimatehpmA INCONSISTENT alpha-hydroxyalprazolam POSITIVE INCONSISTENT

Lorazepam POSITIVE CONSISTENT *THC-Delta-9-COOH POSITIVE INCONSISTENTOxycodone POSITIVE CONSISTENT Methylone POSITIVE INCONSISTENTOxymorphone POSITIVE CONSISTENT

EVITISOP enodocyxoroN CONSISTENT

SPECIMEN VALIDITY TESTING IMMUNOASSAY SCREEN REPORTTEST RESULTS FLAG EXPECTED RESULTS DRUG RESULTS

eninitaerC 225 NORMAL 20 - 300 THC POSITIVE Hp 7.0 NORMAL 4 - 9 Barbiturates Negative

ytivarG cificepS 1.015 NORMAL 1.005 - 1.035 Ethanol NegativeAmphetamines NegativeCocaine Metabolite NegativePCP NegativeOxycodone POSITIVEMDMA Negative6MAM NegativeBenzodiazepines POSITIVEOpiates NegativeBuprenorphine NegativeEthyl Glucuronide NegativeSynthetic Cannab (K2) POSITIVE

CONFIRMATION RESULTS.cnoCffotuCstluseRneercS tseT

AMPHETAMINES detceteD toN enimatehpmA 50 ng/mL detceteD toN enimatehpmahteM 100 ng/mL

BENZODIAZEPINESalpha-hydroxyalprazolam POSITIVE 50 ng/mL 752 ng/mL 7-AminoClonazepam Not Detected 50 ng/mL

Lm/gn 008> Lm/gn 001 EVITISOP mapezaroL detceteD toN mapezaidroN 100 ng/mL detceteD toN mapezaxO 100 ng/mL detceteD toN mapezameT 100 ng/mL

alpha-hydroxymidazolam Not Detected 50 ng/mLalpha-hydroxytriazolam Not Detected 100 ng/mL

OPIATES/OPIOIDS detceteD toN eniedoC 50 ng/mL detceteD toN enihproM 50 ng/mL detceteD toN enodocordyH 50 ng/mL detceteD toN enohpromordyH 50 ng/mL detceteD toN enodocordyhroN 50 ng/mL EVITISOP enodocyxO 50 ng/mL 245 ng/mL EVITISOP enohpromyxO 50 ng/mL 112 ng/mL

egaP0396-213)468(.CLL ,ECRUOSBAL.ylno sesoprup citsongaid lacinilc rof era nevig stluser ehT 1

Client: CLINIC TESTClient #: 54Chart #: A1211130074 Provider: TEST, PHYSICIAN DR

Patient: DOE, JOHNDOB: 01/01/1960Gender: MSpecimen Type: URINE

Lab Acc#: 1304240019Collected: 04/24/13 Received: 04/24/13 09:06Reported: 04/24/13 09:15

Noroxycodone POSITIVE 50 ng/mL 553 ng/mL SYNTHETIC OPIOIDS

Buprenorphine Not Detected 5 ng/mL Norbuprenorphine Not Detected 10 ng/mL Fentanyl Not Detected 2.5 ng/mL Norfentanyl Not Detected 2.5 ng/mL Methadone Not Detected 50 ng/mL EDDP Not Detected 50 ng/mL Meperidine Not Detected 50 ng/mL Normeperidine Not Detected 50 ng/mL Tramadol Not Detected 50 ng/mL O-desmethyl-Tramadol Not Detected 50 ng/mL Pentazocine Not Detected 10 ng/mL Propoxyphene Not Detected 50 ng/mL Tapentadol Not Detected 10 ng/mL

TRANQUILIZERS Meprobamate Not Detected 50 ng/mL Carisoprodol Not Detected 50 ng/mL

ILLICITS Benzoylecgonine (Cocaine) Not Detected 50 ng/mL Phencyclidine (PCP) Not Detected 10 ng/mL *THC-Delta-9-COOH POSITIVE 15 ng/mL 77 ng/mL MDMA (Ecstasy) Not Detected 50 ng/mL

BATH SALTS MDPV Not Detected 50 ng/mL Mephedrone Not Detected 50 ng/mL 4-Fluoromethcathinone Not Detected 50 ng/mL Methylone POSITIVE 50 ng/mL 125 ng/mL Methedrone Not Detected 50 ng/mL

ANTICONVULSANT Gabapentin 998

The results given are for clinical diagnostic purposes only. LABSOURCE, LLC. (864)312-6930 Page 2