Toxicology Test Requisition

10 PANEL & 13 PANEL SCREENING , Specimen validity is included

I certify that I voluntarily provided a fresh and unadulterated urine specimen for analytical testing. The information provided on this form and on the label offered to the specimen cup is accurate. I authorize Avantic to release the results to the treating authorized healthcare provider or facility. I hereby authorize my insurance benefits to be paid directly to Avantic for services I received. I understand that Avantic may be an out of network provider with my insurer. I also understand that sometimes my insurance will send the payment directly to me. I agree to endorse the insurance check and send it to Avantic immediately. Failure to send payment within 30 days of Labelc receipt could result in my account being turned over to collections and reported to the Credit Burreau.

I authorize the above ordered list(s)