instruction booklet - cordant health...

For more information, visit www.cordantsolutions.com, email [email protected] or call 1-855-895-8090.©2016 Cordant Health Solutions™. All rights reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.

Section 1: Practice InformationThe practice name, address and other information should be preprinted by Cordant Health Solutions™ in this section. Please confirm that all the information is complete and accurate. If this section is not preprinted, please discard the blank form and order new forms by calling 1-855-895-8090 and selecting the customer service option.

Section 2: Patient InformationFor the lab to process the specimen, accurate and complete patient information must be supplied. All information in this section is necessary to avoid any delays in processing. The patient name and date of birth must be clearly printed on the requisition. To streamline the process, a patient face sheet containing the remaining demographic information may be supplied in lieu of completing the items in this section. The patient must read the “All Patients” notice and sign and date where indicated.

Section 3: Specimen InformationPlease record the date and time of the specimen collection, along with the collector’s name. A collection time and date must be listed on every form. Please check the appropriate box to confirm that the temperature of the specimen is within range as indicated; otherwise, denote the actual temperature.

Section 4: Billing InformationPlease select one of the following billing options:

• Bill Ordering Agency—Your clinic, hospital or agency will receive an invoice for the testing requested. If you would like your clinic, hospital or ordering agency to receive an invoice for the testing, please mark Bill Ordering Agency.

If you do not want the testing services ordered to be billed to your clinic, hospital or agency, select one of the options below.

• Bill Patient—Bill the patient for the testing requested. Check this box for patients with no health insurance or who desire to pay out of pocket. Providers may also select financial hardship for patients who qualify (patients who are at or below 300% of the federal poverty threshold based on family size and income).

• Bill Insurance (INS)—Bill the insurance provided by the patient for the testing requested. If this box is checked, the patient information must be completed. Check the box where indicated and include a copy of the patient’s insurance card (front and back) and/or a face sheet if all insurance and patient information is up-to-date. In the case of workers’ comp testing, all sections of the Bill Insurance (INS) section must be filled out, including date of injury, claim number, state of injury and employer name/address, in order to avoid processing delays.

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This proof is submitted for your review and approval. It is supplied for content, layout, and version review and does not reflect paper or ink match. Please review your proof carefully.

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Write in - Singular Analyte/ Metabolite Test Orders

* Quan� ta� on will be ordered and billed for all group components.** Test will only be ordered as a refl ex test following a posi� ve methamphetamine confi rma� on. To order, select the Amphetamines box and the D/L Methamphetamine box.

DRUG CLASS COMPONENTS ON BACK

LABORATORY USE ONLY

Ver 6 Rev. 1.0 SHS-003 ORIGINAL - LABORATORY COPY PINK - PHYSICIAN COPY

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Donor Ini� alsDate Collected

Collector Ini� als

1. PRACTICE INFORMATION 6. DRUG TEST ORDERS

AFFIX BARCODE LABEL TO SPECIMEN CONTAINER

LABORATORY URINE DIRECT DEFINITIVE TESTING REQUISITION

To order, place an X or otherwise mark in the secti ons below. Selecti ng Order Group will order all listed tests within bolded secti on. Marking Positi ve Results will order a direct defi niti ve test.

2. PATIENT INFORMATION – AS SEEN ON INSURANCE CARD; USE ONLY BLUE OR BLACK INK(Last): (First): (M.I.):

Date of Birth: / / M F

Phone#:

Pa� ent ID#: SS#:

Address, City, State, Zip:

All Pati ents: I agree that Cordant Health Solu� ons (Cordant) will furnish to my designated insurance provider the informa� on on this form necessary for reimbursement. I hereby authorize the ordered service(s) to be performed by Cordant and also direct that benefi ts shall be payable to Cordant. Cordant is authorized to fi le claims with my insurance provider and to receive payment of benefi ts for the tests my physician orders. I further authorize Cordant and my physician to release to my insurance provider any medical informa� on necessary for these claims. I understand that I am responsible for any amounts not paid by my insurance provider for reasons including, but not limited to, denial, noncoverage, or nonauthorized services. I further consent to tes� ng, understanding that if Cordant is not contracted with my insurance carrier, I will be responsible for any copay, co-insurance or deduc� ble amounts as indicated in my out-of-network Explana� on of Benefi ts. If my insurance provider pays me directly, I agree to endorse the check and forward it to Cordant within 30 days. In addi� on to assigning all payments to Cordant, I hereby assign all of my related rights and obliga� ons under my insurance plan to Cordant and its representa� ves, including specifi cally the right to fi le claims, li� gate and appeal claim denials and pursue causes of ac� on under ERISA. I permit a signature on fi le or copy of this authoriza� on to be used in place of the original.

7. CURRENT PRESCRIBED MEDICATIONS No Medicati ons PrescribedPrescribed Medicati ons List Att ached

Place an X or otherwise mark in the associated box for prescribed medications. A test will not be ordered unless “Quantitate Prescribed Medications” is selected.

Quanti tate Prescribed Medicati ons

Physician Signature:

Diagnosis Code(s): Ordering Physician:

Sertraline (Zolo� )Tapentadol (Nucynta)Temazepam (Restoril)THC (Marinol)Tramadol (Ultram)Trimipramine (Surmon� l)Venlafaxine (Eff exor)Zaleplon (Sonata)Zolpidem (Ambien)Zopiclone (Lunesta)Other:______________________ Other:______________________ Other:______________________

Alprazolam (Xanax)Amitriptyline (Elavil)Amphetamine (Adderall)Aripiprazole (Abilify)Buprenorphine (Suboxone, Buprenex)Bupropion (Wellbutrin)Butalbital (Fioricet, Fiorinal)Carisoprodol (Soma)Citalopram (Celexa)Clomipramine (Clofranil)Clonazepam (Klonopin)Clozapine (Clozaril)Codeine (Tylenol #3)

Cyclobenzaprine (Flexeril)Desipramine (Norpramin)Desmethylvenlafaxine (Pris� q)DextromethorphanDiazepam (Valium)Doxepin (Deptran)Duloxe� ne (Cymbalta)EphedrineFentanyl (Duragesic, Ac� q)Fluoxe� ne (Prozac)Gabapen� n (Neuron� n)Haloperidol (Haldol)Hydrocodone (Vicodin, Norco)

Hydromorphone (Dilaudid)Imipramine (Tofranil)Ketamine (Ketalar)Lorazepam (A� van)Mapro� line (Deprilept)Meperidine (Demerol)Methadone (Dolophine)Methylphenidate (Ritalin)Morphine (Kadian, MSIR)Naloxone (Narcan)Naltrexone (Vivitrol)Nortriptyline (Pamelor)Olanzapine (Zyprexa)

Oxazepam (Serax)Oxycodone (OxyCon� n, Percocet)Oxymorphone (Opana)Paroxe� ne (Paxil)Pentazocine (Talwin)Phenobarbital (Luminal)PhenterminePregabalin (Lyrica)Propoxyphene (Darvon)Protriptyline (Vivac� l)Que� apine (Seroquel)Risperidone (Risperdal)Secobarbital (Seconal)

Pa� ent Signature: Date:

Date Collected:MM/DD/YYYY

Time: : AM PM

Collector’s Name:

3. SPECIMEN INFORMATION

Temperature: (read within 4 minutes of collec� on)Specimen is in the range of 90.5°F and 99.8°F

5. PHYSICIAN NOTICE-ABN & ADDITIONAL INFORMATION PROVIDED ON REVERSE SIDEMEDICAL NECESSITY: You should only order laboratory tests that are reasonable and medically necessary for your pa� ent. Upon request, you must be able to produce documenta� on to support the medical necessity of the laboratory tests you have requested the laboratory to perform.

ADVANCE BENEFICIARY NOTICE (ABN): When you order a laboratory test for a pa� ent that is a Medicare benefi ciary and have a reasonable belief that Medicare will not pay for the laboratory test, the pa� ent must complete and sign the ABN on the reverse side of this requisi� on form.

4. BILLING INFORMATION-FILL OUT 1 OF 3 OPTIONS. BILL ORDERING AGENCY, BILL PATIENT OR BILL INSURANCE

Bill Insurance (INS): - A copy of insurance card and/or face sheet is a� ached

Bill Ordering Agency

Medicare Medicaid Commercial INS Workers’ Comp (WC) Motor Vehicle Accident (MVA)

INS NAME: Policy / ID #

Claim Address:

MVA/WC Claim #:

Employer Name:

Employer Address:

/ /

If no, Actual Temp:YES NO

Bill Pati ent: Self-Pay Financial Hardship

Employer Phone #:

Date ofInjury: / /

State ofInjury:

Qualifi ca� on for fi nancial hardship is based on family size and incomeless than or equal to 300% of the current Federal Poverty Level.

Direct Defi niti ve Testi ng Orders

Opioid Group Order Group* Opiates Oxycodone/Oxymorphone Buprenorphine Fentanyl Methadone TramadolIllicit and Drugs of Abuse Group Cannabinoids, natural (THC) Cocaine Ecstasy (MDA, MDEA, MDMA) Heroin metabolite (6-acetylmorphine) PhencyclidineIndividual Drugs Alcohol (Ethanol) An� depressants, Tricyclic & other cyclicals Amphetamines Barbiturates Benzodiazepines Carisoprodol PropoxypheneAlcohol Biomarkers (EtG/EtS)An� depressants; not otherwise specifi edAn� depressants, serotonergic classCannabinoids, synthe� cCyclobenzaprineD/L Methamphetamine**Gabapen� nKetamineKratom (Mitragynine)MethylphenidateNico� ne (co� nine)Opioids and Opiate AnalogsPregabalinSeda� ve hypno� csS� mulants, synthe� c (Bath Salts)TapentadolAdulterants - SCREEN ONLYValidity Group - Crea� nine, pHValidity Test – Crea� nineValidity Test – OxidantsValidity Test – pHValidity Test – Specifi c Gravity

Positi ve Results

SECTION 1

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Phone#:

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Time: : AM PM

Collector’s Name:










Claim Address:

MVA/WC Claim #:

Employer Name:

Employer Address:

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Employer Phone #:

Date ofInjury: / /

State ofInjury:




Positi ve Results

SECTION 2

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Time: : AM PM

Collector’s Name:










Claim Address:

MVA/WC Claim #:

Employer Name:

Employer Address:

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Employer Phone #:

Date ofInjury: / /

State ofInjury:




Positi ve Results

SECTION 3

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Positi ve Results

SECTION 4

INSTRUCTION BOOKLETPOINT-OF-CARE URINE TESTINGRequisition “K” Form


Section 5: Physician NoticeDiagnosis code(s) (ICD-10) and the name of the ordering physician are required on every form that is billed to insurance. Provide the appropriate diagnosis codes to support the medical necessity of all testing requested. For Medicare patients, submit a properly completed ABN (page 1 backer) signed by the patient for any test that you have reason to believe Medicare will not cover. Please supply the ordering physician’s NPI number if they are new to your practice and contact Cordant’s customer service department to add that physician to your account. A physician signature is highly recommended by all providers and required by ordering providers for MA, NJ, NY and PA Medicaid beneficiaries.

Section 6: Drug Test Orders - Urine Drug Testing Device / In-Office Analyzer• In the “Positive Results” column of section 6,

note any positive results by placing an X in (❶) for the screening tests performed at the time of collection using a CLIA-waived urine collection device or an immunochemistry analyzer. Marking Positive Results will order a direct definitive test for that drug.

• If quantitative testing is needed for a test that may have not been screened on-site, place a mark in the “Orders” column of section 6 (❷). This will order a direct definitive test for any drugs selected. Note that if the “Order Group” check box (❸) is selected for the “Opioid Group,” definitive testing will be performed and reported for all the drugs within the opioid group as listed. The opioid group is the only grouping on the point-of-care urine form that has this option.

• If adulterant tests are required, select from the section provided. This will indicate that a screening test is needed for the selected adulterants. Validity testing is not processed as a direct definitive test.

• If testing at the analyte level is needed, write the needed test in the “Write in – Singular Analyte/Metabolite Test Orders” box (❹). Please discuss use of this section with your sales representative or with Cordant customer service to ensure that tests requested can be processed. Also, please reference page 2 of the back of the requisition form for a listing of the current analytes offered by Cordant.

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Claim Address:

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Employer Name:

Employer Address:

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Employer Phone #:

Date ofInjury: / /

State ofInjury:




Positi ve Results

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Positi ve Results

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Positi ve Results

❸

❹

❶

❷

SECTION 5

SECTION 6


Section 7: Current Prescribed MedicationsCheck the box next to the name of the medication the patient is currently being prescribed. If testing is desired for these medications, check the “Quantitate Prescribed Medications” box in the header to order a direct definitive test for any marked medication. This can be used with or without section 6 filled out. If the patient does not have any medications prescribed, check the “No Medications Prescribed” box in the header. If a medication is not listed, write that medication in the space provided next to the “OTHER” option and check the associated box. If a current medications list is available, attach that to the requisition when submitting the testing to the lab with the specimen and check the “Prescribed Medications List Attached” box in the header. If you attach a current medications list, you still need to check the “Quantitate Prescribed Medications” box if you want those medications tested.

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Employer Address:

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Date ofInjury: / /

State ofInjury:




Positi ve Results

BACKERS: ABN AND DRUG CLASS COMPONENTSOn the back of page 1: Advanced Beneficiary Notice of Noncoverage

Explanation

Medical providers are required to present an Advance Beneficiary Notice of Noncoverage (ABN), also known as a waiver of liability, when offering patient services or items that the provider knows or has reason to believe Medicare will deny coverage for and therefore will not pay for the services provided.

Providers are not required to give the patient an ABN for services or items explicitly excluded from Medicare coverage (items that are never covered by Medicare even if medically necessary, such as hearing aids). In addition, ABNs apply only to patients covered by original Medicare, not Medicare private health plans (HMOs, PPOs or PFFSs).

If a provider has any reason to believe that the services provided will not be covered, the provider/patient must fill out the ABN form.

How to Complete the Form Provided

The patient or provider will need to fill out sections A, B and C (notifier, patient name and identification number). The notifier is the provider’s office. The patient name is the full name of the patient. The identification number is the patient ID number that is used at the provider’s facility to identify the patient.

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A. Notifi er:B. Patient Name: C. Identifi cation Number:

Advance Benefi ciary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.Medicare does not pay for everything, even some care that you or your health care provider havegood reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you fi nish reading. • Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. listed above. You may ask to be paid now, but Ialso want Medicare billed for an offi cial decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsiblefor payment, but I can appeal to Medicare by following the directions on the MSN. If Medicaredoes pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the D. listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3. I don’t want the D. listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare would pay.H. Additional Information:

This notice gives our opinion, not an offi cial Medicare decision. If you have other questions onthis notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Offi cer, Baltimore, Maryland 21244-1850.

Form Approved OMB No. 0938-0566Form CMS-R-131 (03/11)

SECTION 7


In section D the patient/provider must list the services or items provided. Section E details the reason Medicare or another insurance provider may not pay for the services. Section F should be completed by the provider and include 100% Medicare Allowable Rates for the ordered tests.

In section G, the patient will need to select one of three options that confirm whether the patient wants the testing/services listed in section D and, if yes, how to handle the billing and payment.

Section H is for additional information and is not a required field.

The patient will need to sign and date this document in sections I and J.

On the back of page 2: Drug Class ComponentsAll the drug class components are located on the back for the provider’s reference. Each of the test options from section 6 is listed here and broken down to include the metabolites found via direct definitive testing. The components may vary from laboratory to laboratory and from specimen type to specimen type. Please contact your sales representative or customer service if there are any questions about testing capabilities.

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A. Notifi er:B. Patient Name: C. Identifi cation Number:

Advance Benefi ciary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.Medicare does not pay for everything, even some care that you or your health care provider havegood reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you fi nish reading. • Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. listed above. You may ask to be paid now, but Ialso want Medicare billed for an offi cial decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsiblefor payment, but I can appeal to Medicare by following the directions on the MSN. If Medicaredoes pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the D. listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3. I don’t want the D. listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare would pay.H. Additional Information:

This notice gives our opinion, not an offi cial Medicare decision. If you have other questions onthis notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Offi cer, Baltimore, Maryland 21244-1850.

Form Approved OMB No. 0938-0566Form CMS-R-131 (03/11)

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COMPONENTS MAY VARY FROM LABORATORY TO LABORATORY AND FROM SPECIMEN MATRIX TO SPECIMEN MATRIX.

ALCOHOL BIOMARKERethyl glucuronide

ethyl sulfate

ALCOHOLSethanol

AMPHETAMINESamphetaminemethamphetaminephentermine

ephedrine

ANTIDEPRESSANTS, NOT OTHERWISE SPECIFIED13chlorophenylpiperazinenefazodonetrazodonevenlafaxinedesmethylvenlafaxinebupropion

hydroxybupropion

ANTIDEPRESSANTS, SEROTONERGIC CLASScitalopramdesmethylcitalopramduloxe� nefl uoxe� nefl uvoxaminenorfl uoxe� nenorsertralineparoxe� nesertraline

vilazodone

ANTIDEPRESSANTS, TRICYCLIC & OTHER CYCLICALS8hydroxyamoxapineamitriptylineamoxapineclomipraminedesipraminedesmethylclomipraminedesmethyldoxepindesmethylmirtazapinedoxepinimipraminemapro� linemirtazapinenortriptylineprotriptyline

trimipramine

ANTIPSYCHOTICS, NOT OTHERWISE SPECIFIED7hydroxyque� apine9hydroxyrisperidonearipiprazoleclozapinedehydroaripiprazoledesmethylclozapinedesmethylolanzapinenorque� apineolanzapineque� apinerisperidone

haloperidol

BARBITURATESbutalbitalphenobarbitalsecobarbitalamobarbital

pentobarbital

BENZODIAZEPINES7aminoclonazepamalphahydroxyalprazolamalprazolamlorazepamnordiazepamoxazepamtemazepamdiazepamclonazepam

chlordiazepoxide

BUPRENORPHINEbuprenorphine

norbuprenorphine

CANNABINOIDS, NATURALTHC Metabolite

THC

CANNABINOIDS, SYNTHETICJWH-073 N-propanoic acidJWH-200 5-hydroxyindoleJWH-203 n-pentanoic acidJWH-210 N-(5-hydroxypentyl)JWH-018 N-(5-hydroxypentyl)JWH-018 N-pentanoic acidJWH-019 N-(6-hydroxyhexyl)JWH-073 N-(4-hydroxybutyl)JWH-073 N-butanoic acidJWH-081 N-5-hydroxypentylJWH-122 N-5-hydroxypentylJWH-250 N-(5-hydroxypentyl)JWH-398 N-pentanoic acidAKB-48 n-pentanoic acidAM-2201 N-(4-hydroxypentyl)AM-694 n-pentanoic acid

MAM2201 n-pentanoic acid

5-Fluoro-PB-22 carboxyindolePB-22 3-CarboxyindoleBB-22 3-CarboxyindoleRCS-4 N-(5-hydroxypentyl) phenol, M10RCS-4 N-(5-hydroxypentyl)UR-144 N-pentanoic acidUR-144 pyrolysis n-pentanoic acidXLR-11 6-hydroxyindoleXLR-11 N-(4-hydroxypentyl)AB-PINACA N-(4-hydroxypentyl)AB-FUBINACA metaboliteAB-PINACA pentanoic acidADB-PINACA pentanoic acidADBICA n-pentanoic acid

5-Fluoro AB-PINACA N-(4-hydroxypentyl)

CARISOPRODOLcarisoprodol

meprobamate

COCAINEbenzoylecgonine

cocaine

CYCLOBENZAPRINEcyclobenzaprine

FENTANYLacetylfentanylacetylnorfentanylfentanyl

norfentanyl

GABAPENTINgabapen� n

HEROIN METABOLITE6acetylmorphine

KETAMINE AND NORKETAMINEketamine

norketamine

KRATOM7hydroxymitragynine

mitragynine

METHADONEeddp

methadone

METHYLENEDIOXYAMPHETAMINESmdamdea

mdma

METHYLPHENIDATEmethylphenidate

ritalinic acid

NICOTINE/COTININEco� nine

nico� ne

OPIATEScodeinehydrocodonehydromorphonemorphine

norhydrocodone

OPIODS AND OPIATE ANALOGS6betanaltrexoldextromethorphandextrorphanmeperidinenaloxonenaltrexonenormeperidine

pentazocine

OXYCODONEnoroxycodoneoxycodone

oxymorphone

PHENCYCLIDINEphencyclidine

PREGABALINpregabalin

PROPOXYPHENEnorpropoxyphene

propoxyphene

SEDATIVE HYPNOTICS NONBENZODIAZEPINESzaleplonzolpidem

zopiclone

STEREOISOMER ENANTIOMER ANALYSISmethamphetamine

STIMULANTS, SYNTHETICEthyloneButyloneMethedroneMethylenedioxypyrovaleroneNaphyroneMephedroneMethyloneMethcathinoneFlephedroneα-PBPα-PVP

DMAA

TAPENTADOLtapentadol

TRAMADOLdesmethyltramadol

tramadol

DRUG CLASS COMPONENTS

To order additional forms, call:

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Cordant has created a separate document for information on processing, packing and shipping specimens.

Please contact Cordant at this number for a copy of these instructions.

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Phone#:

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Claim Address:

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Employer Phone #:

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Positi ve Results

SAMPL

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D O EJ O H N

John Doe 6/2/2016

8910 Some Street, Some Town, CO 88888

1 21 2 3 4 5 6 7 8 9 A B C D E F G 1 2 3 4 5 6 7 8 9

113 9 5 0 5 5 5 5 5 5 5 5 5 5T

0 6 0 2 2 0 1 6 1 2 2 2L JI O SS H OA N N

A12.345 Dr. Seuss

Sample Name 1234 Any Street, Any Town, CO 88888 Account# XXXXX

67890 Any Street, Any Town, USA 98765

Dr. Seuss

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