Welcome to Crestar Labs.

practice name

practice phone xxx-xxx-xxxx practice fax xxx-xxx-xxxx (for sending Patient Health Information)

practice address city state zip

contact person contact phone contact email

Practice ProfileMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

representative distribution group clinic start date

Name (last name, first) NPI #

Name (last name, first) NPI #

Name (last name, first) NPI #

Practice Fusion (coming soon)

Hours of Operation

Primary Location Open Time Close Time Desired UPSPick-Up Time

Thursday

Friday

Saturday

If shipping pickup needs to be coordinated, please indicate a pickup location (front desk, dock, etc.

Genetic Spec imens Per Week

Collections Performed?Primary Location Open Time Close Time Desired UPS

Pick-Up TimeCollections Performed?

Monday

Tuesday

Wednesday

Practice Fusion (availableafter evaluation period)

Ordering Preferences Paper Requisition (default)

Historical Summary added to Standard ReportProviders

Account NotesToxicology Specimen Per Week

Payor Information Medicare/Tricare Medicaid Commercial

Clinic Specialty

Worker's Comp Self Pay

Web (coming soon)

Fax (will send to practice fax)Reporting Preferences Web (default)

Please note Medicaid & Commercial Payors(s) here:

Additional Comments

NPI # Name (last name, first)

Name (last name, first) NPI #

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

position in clinic

rev 20170801

Page 1 of 8

practice name - additional location

practice phone xxx-xxx-xxxx practice fax xxx-xxx-xxxx (for sending Patient Health Information)

practice address city state zip

contact phone contact email

Practice Profile Additional LocationMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

contact person

Hours of Operation

Additional Location Open Time Close Time Desired UPSPick-Up Time

Thursday

Friday

Saturday

If shipping pick-up needs to be coordinated, please indicate a pickup location (front desk, dock, etc.

Collections Performed?Additional Location Open Time Close Time Desired UPS

Pick-Up TimeCollections Performed?

Monday

Tuesday

Wednesday

Practice Fusion (coming soon)

Practice Fusion (availableafter evaluation period)

Web (coming soon)

Fax (will send to practice fax)

Name (last name, first) NPI #

Name (last name, first) NPI #

Name (last name, first) NPI #

NPI # Name (last name, first)

Welcome to Crestar Labs.

ADDITIONAL COMMENTS

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

Ordering Preferences Paper Requisition (default)

Reporting Preferences Web (default)

Historical Summary added to Standard Report

Providers

position in clinic

rev 20170801

Page 2 of 8

URINE TOXICOLOGY *Enter desired quantities based on available increments

ACCOUNT INFORMATION

ORAL FLUID TOXICOLOGY *Enter desired quantities based on available increments

PHARMACOGENETICS *Enter desired quantities based on available increments

practice name

practice address

practice email or contact

representative/distributor

city

practice phone xxx-xxx-xxxx

state zip

date

Please note any special requests or instructions. If shipping supplies to distributor, please indicate distributor shipping address. Email completed forms to support@crestarlabs.com or fax to 615-302-8553

All orders must be received by 2:30 pm (cst) for same day shipping. Allow 2-5 business days for delivery.

All subsequent supply requests for this clinic should be sent through www.crestarlabs.com/order-supplies

Pre-printed shipping labels 25 / 50 / 75 / 100 Quantity _______

Laminated Collection Guide 1 / 2 / 3 / 4 Quantity _______

Collection cups 25 / 50 / 75 / 100 / 150 / 200 Quantity _______

Toxicology Requisition forms 25 / 50 / 75 / 100 / 150 / 200 Quantity _______

UPS SHIPPING SUPPLIES *Enter desired quantities based on available increments

Laboratory Pak bags + absorbant pad 25 / 50 / 75 / 100 Quantity _______

❑

❑ ❑

❑

❑

INTERNAL USE ONLY Order completed by: Ship date:

❑ Pre-printed clinic labels 50 / 100 / 150 / 200 Quantity _______

Comments

❑ Specimen Collection bags 25 / 50 / 75 / 100 / 150 / 200 Quantity _______

Laminated Collection Guide 1 / 2 / 3 / 4 Quantity _______

Quantisal Collection devices 25 / 50 / 75 / 100 Quantity _______

❑ ❑

❑ ❑

Toxicology Requisition forms 25 / 50 / 75 / 100 / 150 / 200 Quantity _______

Pre-printed clinic labels 50 / 100 / 150 / 200 Quantity _______

❑ Specimen Collection bags 25 / 50 / 75 / 100 Quantity _______

Laminated Collection Guide 1 / 2 / 3 / 4 Quantity _______

Buccal Swab Collection devices 25 / 50 / 75 / 100 Quantity _______

❑ ❑

❑ ❑

Pharmacogenomic Requisition forms 25 / 50 / 75 / 100 Quantity _______

Pre-printed clinic labels 50 / 100 / 150 / 200 Quantity _______

❑ Specimen Collection bags 25 / 50 / 75 / 100 Quantity _______ ❑ Informed Consents 1 / 25 / 50 / 75 / 100 Quantity _______

Ship direct to Clinic❑ Ship to Distributor❑

Start-Up Supply OrderMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

❑ Laboratory Pak Address Pouches 25 / 50 / 75 / 100 Quantity _______

rev 20170801

Page 3 of 8

* Initial supply orders may also be requested online HERE

Please Use Custom Profile Code: TOXH TOXM TOXL

CLASSHigh Risk

M oderate Risk

Low Risk

ALCOHOLS EtG/EtS Alcohol Metabolite x x

Methamphetamine D/L isomerMethamphetamine/Desoxyn® Amphetamine/Adderall®, Vyvanse® Methylphenidate/Concerta® , Ritalin® Phentermine/Adipex-P ®, Suprenza ®

Carbamazepine/Tegretol®,Carbatrol®,Epitol®Gabapentin/Neurontin® Pregabalin/Lyrica®

Amitriptylline/Elavil® Doxepin/Sinequan® Imipramine/Tofranil ® Venlafaxine/Effexor® Paroxetine/Paxil® Citalopram/Celexa® Sertraline/Zoloft®

Nortriptylline/Pamelor® Duloxetine/Cymbalta® Desipramine/Norpramin® Desvenlafaxine/Pristiq® Fluoxetine/Prozac® Olanzapine/Zyprexa® Trazodone/Oleptro®

Butalbital/Fiorinal®, Fioricet® Pentobarbital/Nembutal®

Phenobarbital Secobarbital/Seconal®

Alprazolam/Xanax® Chlordiazepoxide/Librium® Diazepam/Valium® Oxazepam/Serax®

Clonazepam/Klonopin® Lorazepam/Ativan® Nordiazepam/Nordaz® Temazepam/Restoril®

Flunitrazepam/Rohypnol® Midazolam

Flurazepam/Dalmane® Triazolam

Benzoylecgonine (Cocaine) PCP (Angel Dust)MDEA (Ecstasy, Eve)THC-COOH/Marinol® (Marijuana)

Mitragynine (Kratom)

6-MAM Ketamine/Ketalar®MDMA (Ecstasy) MDA (Molly)

Desomorphine (Krokodil) Dihydrokavain (Kava)Designer Cathinones (Bath Salts) Synthetic Cannabinoids(Spice/K2)

Meprobamate/Equanil®Carisoprodol/Soma® Cyclobenzaprine/Flexeril®

NON-BENZOS / SLEEP AIDS

Zaleplon/Sonata® Zolpidem/Ambien® x x

Oxymorphone/Opana® Codeine Hydromorphone/Dilaudid® Morphine/MS Contin®

Oxycodone/Percocet®, Oxycontin®,Percodan® Dihydrocodeine/Synalgos DC®Hydrocodone/Lortab®, Norco®, Vicodin® Buprenorphine/Butrans®, Suboxone®,Subutex®

Fentanyl/Actiq®,Duragesic® Methadone/Methadose® Naltrexone/Vivitrol®, Revia® Propoxyphene/Darvon® Tapentadol/Nucynta®

Meperidine/Demerol® Naloxone/Narcan® Pentazocine/Talwin® Sufentanil/Sufenta® Tramadol/Ultram®

Acetaminophen Dextromethorphan Cotinine (Nicotine)

Confirm Reported Patient Medications x x x

Perform Full Screen x x x

DRUG/MEDICATION

AMPHETAMINES

ANTI- DEPRESSANTS

BENZODIAZEPINES

BARBITURATES

ANTI- CONVULSANTS

ADDITIONAL TESTING

x x

x x

x x

MUSCLE RELAXANTS

ILLICIT DRUGS

NON- PRESCRIPTION

x

x x

x x

x

x

x

x

x

x x

OVER THE COUNTER

x

x x

OPIATES

x x

Urine Toxicology

This account is interested in Urine Toxicology Testing

Crestar offers 3 urine toxicology panels to address your testing needs. When ordering, please enter the appropriate order code in Section E of Crestar’s Toxicology Requisition (ie: for High Risk Panel – enter TOXH as the Panel Code).

Please read the Custom Profile section of the Annual Provider Notice HERE.

Patient Risk PanelsMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

rev 20170801

Page 4 of 8

Please Use Custom Profile Code: HOF LOF

CLASS DRUG/MEDICATION High Risk Low RiskALCOHOLS EtG/EtS Alcohol Metabolite x

Methamphetamine/Desoxyn®

Amphetamine/Adderall®, Vyvanse®

Alprazolam/Xanax®

Diazepam/Valium®

Nordiazepam/Nordaz®

Temazepam/Restoril®

Oxazepam/Serax®

Clonazepam/Klonopin®

Lorazepam/Ativan®

6-MAMHeroinBenzoylecgonine (Cocaine)Ketamine/Ketalar® NorketamineMDMA (Ecstasy)MDA (Molly)PCP (Angel Dust)THC-COOH/Marinol® (Marijuana)

CodeineHydrocodone/Lortab®, Norco®, Vicodin®

NorhydrocodoneHydromorphone/Dilaudid®

Morphine/MS Contin®

Buprenorphine/Butrans®, Suboxone®

NorbuprenorphineFentanyl/Actiq®,Duragesic®

Norfentanyl Meperidine/Demerol®

Normeperidine Methadone/Methadose®

EDDPNaloxone/Narcan® (ingredient in Suboxone®) Tramadol/Ultram®

Oxycodone/Percocet®, Oxycontin® NoroxycodoneOxymorphone/Opana®

x

x

x x

AMPHETAMINES

BENZODIAZEPINES

ILLICIT DRUGS

OPIATES

x

x

This account is interested in Oral Fluid Toxicology Testing

Crestar offers two Oral Fluid Panels to address your testing needs. When ordering, please enter the appropriate order code in Section E of Crestar’s Toxicology Requisition (ie: for High Risk Panel – enter HOF as the Panel Code, for Low Risk Panel – enter LOF as the Panel Code).

Please read the Custom Profile section of the Annual Provider Notice HERE.

Oral Fluid Toxicology

Patient Risk PanelsMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

rev 20170801

Page 5 of 8

Panel Associated Drug Class Targeted GenesGEN_COMP Anti-ADHD

AntiarrhythicsAnticoagulantsAnticonvulsantsAntidementia AgentsAntidepressantsAntidepressant TCAsAntidiabeticsAntifungals/Antivirals ANKK1Antiplatelet Agents APOEAntipsychotics ATMAnxiolytics COMTBeta-blockers Factor IICholinergic Agents Factor VContraceptives GRIK4Hypnotics HLA-BImmunosuppressants HTR2AMuscle Relaxants MTHFRAPOE OPRM1Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) SLCO1B1Opioids TPMTProton Pump Inhibitors (PPI) VKORC1Selective Serotonin Reuptake Inhibitors (SSRIs)Statins

GEN_CARD AntiarrhythicsAnticoagulantsAnticonvulsants APOEAntiplatelet Agents Factor II & Factor VBeta-blockers MTHFRAPOE Genotype SLCO1B1Statins VKORC1

GEN_MENT Anti-ADHDAnticonvulsantsAntidementia AgentsAntidepressantsAntidepressants TCAsAntipsychotics HLA-BAnxiolytics MTHFRHypnoticsSelective Serotonin Reuptake Inhibitors (SSRIs)

GEN_AI AnticonvulsantsAntidepressantsAntipsychotics (Olanzapine Only)Cholinergic AgentsImmunosuppressants HLA-BMuscle Relaxants MTHFRNonsteroidal Anti-Inflammatory Drugs (NSAIDs) TPMTOpioids

Factor II relative to CoagulationFactor V relative to CoagulationMTHFR (Methylene tetrahydrofolate reductase) relative to homocysteine levels, folate metabolismFactor II + Factor V + MTHFR Genetic Thrombosis Risk (including Estrogen Supplementation)

Cytochrome P450 Genes 2D6 2C9 2C19 3A4 3A5

Anti-Inflammatory Wellness

Additional Panels -

May Add to a Wellness Panel or Order

Individually

APOE (Apolipoprotein E) relative to Lipid Metabolism ATM MetforminCYP2C9 Anticoagulants, Antidiabetics, NSAIDs, PhenytoinCYP2C9 + CYP4F2 + VKORC1 WarfarinCYP2C19 Carisoprodol, Clobazam, Clopidogrel, Imipramine, Moclobemide, Proton Pump Inhibitors, SSRIs, VoriconazoleCYP2D6 Atomoxetine , Antiarrhythmics, Antidepressants, Antipsychotics, Beta Blockers, Cevimeline, Donepezil, Opioids, SSRIsHLA-B Abacavir, Carbamazepine

Cytochrome P450 Genes1A2 2B6

2D6 2C9 2C193A4 3A5 4F2

Comprehensive Wellness

Cytochrome P450 Genes2D6 2C9 2C19 3A4 3A5 4F2

CardiacWellness

Cytochrome P450 Genes 2D6 2C9 2C19 3A4 3A5

MentalWellness

GEN_APOE

GEN_ATM

GEN_CYP2C9

GEN_VKOR

GEN_CYP2C19

GEN_CYP2D6

GEN_HLAB

GEN_F2

GEN_F5

GEN_MTHFR

GEN_THROMB

This account is interested in Pharmacogenomic TestingCrestar offers 4 pharmacogenomic panels to address your testing needs.

Please read the Custom Profile section of the Annual Provider Notice HERE.

Pharmacogenomics

Patient Risk PanelsMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

rev 20170801

Page 6 of 8

2017 Annual Provider NoticeMarc J. Rumpler, Ph.D., Lab Director / CLIA #44D2080511 2001 Campbell Station Pkwy., STE C-2, Spring Hill, TN 37174 crestarlabs.com

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

The Office of Inspector General (OIG) recommends clinical laboratories send notices to physicians and other health care providers who

use their services, at least once a year, to inform the recipients of the laboratory’s policies for test ordering and billing and provide

certain other information regarding the laws and regulations that govern laboratory services. This Annual Notice is provided pursuant to

that recommendation.

The following information is intended to promote awareness of federal regulations and to explain the requirement for health care

providers to furnish appropriate documentation when ordering testing services. If you have questions about the contents in this notice,

we encourage you to contact us for more information.

Medical Necessity: Medicare will only pay for tests that meet the Medicare coverage criteria and are medically necessary for the

diagnosis or treatment of the individual patient. Criteria to establish medical necessity for drug testing must be based on patient-specific

elements identified during the clinical assessment and documented by the clinician in the patient’s medical record. Tests used for

routine screening of patients without regard to their individual need are not usually covered by the Medicare Program, and therefore

are not reimbursed. As a participating provider in the Medicare Program, Crestar Labs has a responsibility to make a good faith effort to

ensure all tests requested are performed and billed in a manner consistent with all federal and state law regulations. As the physician,

you are responsible for documenting medical necessity in the patient’s permanent medical record and for providing appropriate

diagnostic information in the form of ICD-10 codes to the highest level of specificity or a narrative to Crestar. The Office of Inspector

General takes the position that a physician who orders medically unnecessary tests for which Medicare or Medicaid reimbursement is

claimed may be subject to civil penalties under the False Claims Act.

Medicare National and Local Coverage Determinations: The Medicare Program publishes National Coverage Determinations

(NCDs) and local Medicare contractors publish Local Coverage Determinations (LCDs) for certain tests. These policies identify the

conditions for which the included tests are or are not covered or reimbursed by Medicare with reference to specific ICD codes

(diagnostic information). Medicare contractors have issued LCDs that apply to qualitative drug screens (presumptive tests), confirmatory

or quantitative drug tests (definitive testing), and pharmacogenetic testing furnished within their region of jurisdiction. These policies

are available upon request and can be found through the Medicare website at:

http://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html

Test Ordering: Crestar's web-based platform may be used to order tests from Crestar. Crestar assists health care providers track and

view specimens as they progress through transit, testing and delivery of results. A standard Crestar test requisition form

(whether via the portal or in paper form) should always be used when ordering tests. The Crestar requisition forms are designed to

emphasize physician choice and encourage physicians to order only those tests which the physician believes are appropriate and

medically necessary for the diagnosis or treatment of each patient. If Crestar receives a test order on a non-Crestar requisition form or

an incomplete Crestar requisition form, processing of your test order may be delayed. As necessary, Crestar will contact physicians to

have them resubmit the test order on a test requisition form or otherwise clarify each specific test being ordered.

Crestar, under no circumstances, endorses duplicate billing of tests. If a provider performs a drug screen, and subsequently bills the

insurer for that test, the provider should not order a separate screen from Crestar. Provider’s should notify the laboratory of any change

or addition in their point of care testing in order to avoid duplicate billing of tests. For any requested test(s) ordered by the provider, it

should be expected that Crestar will bill for that test, unless otherwise agreed upon.

Signatures & Intent: To stay within federal regulations for test ordering, Crestar provides multiple options for referral sources to

authorize the processing of specimen. By law, the referring physician must document that a test was ordered with intent, and that a

signature must accompany this documentation. If the physician submits a paper requisition form to Crestar the requisition must: (a)

contain the signature of the physician, (b) be accompanied with signed medical notes containing intent for the test, or (c) the physician

must retain the signed medical notes and make them available to Crestar upon request. If the physician chooses to retain the

documentation, Crestar will need assurance that these supporting documents be retained for no less than the period required by law,

and contain clear intent for the test order and an appropriate signature of the physician. Electronically submitted requisitions must also

abide by the intent, signature, and retention requirements of paper requisitions and Crestar will make accommodations to facilitate this

process for e-submitters.

Elimination of Physician Custom Profiles: Recent policy changes and guidance from Medicare Administrative Contractors, other

government regulatory authorities and commercial insurers now discourage, if not outright prohibit, clinicians’ use of non-

rev 20170801

Page 7 of 8

Name (last name, first) NPI # Signature

Name (last name, first) NPI # Signature

Name (last name, first) NPI # Signature

NPI # SignatureName (last name, first)

NPI # SignatureName (last name, first)

2017 Annual Provider Notice

PROVIDER SIGNATURESBy signing below, I affirm that all information is accurate and that I will comply to the terms discussed in this enrollment documentation

Que

stio

ns -

Con

tact

us a

t sup

port@

cres

tarla

bs.c

om o

r 61

5-85

0-90

10

patient-specific panels, including “custom profiles,” when ordering laboratory drug testing . As such, Crestar has minimized its use of

Physician Custom Profiles. Custom profiles, at minimum, must be reviewed and verified annually to ensure the testing is medically

necessary based on individual patient specific elements identified during the clinical assessment, and documented by the clinician in the

patients’ medical record. As a clinical laboratory, Crestar supports these efforts and has devoted substantial resources to developing

processes that will seamlessly encourage that only medically necessary tests are ordered for each patient. Elimination of “custom profiles”

and adoption of risk-based panels and patient specific ordering without panels is also important for physicians. Health plans and regulatory

authorities are increasingly expecting physicians to strictly comply with new medical policies related to drug test ordering or risk network

termination for non-compliance. Return to Patient Risk Panels HERE

Verbal Test Orders: Medicare regulations require that all orders for laboratory tests be in writing. If a physician or his/her authorized

representative orders a test by telephone or wishes to add a test to an existing order, a written order is required to support the verbal

order. In these cases, Crestar will send a confirmation of the verbal order request to the ordering physician, requesting it to be signed and

sent back to the laboratory for its records. Testing will not be performed until the signed confirmation or a properly completed Crestar

requisition form is returned to the laboratory.

Patient Privacy (HIPAA): Under the Health Insurance Portability and Accountability Act (HIPAA), Crestar is a health care provider and a

covered entity. It is our policy to comply with the letter and intent of the HIPAA privacy and security standards. Our privacy policy is

available upon request.

Inducements: Federal law prohibits offering or paying any remuneration – meaning anything of value – to induce the referral of tests that

are covered by Medicare, Medicaid or other federal health care programs. Any form of kickback, payment or other remuneration that is

intended to secure the referral of federal health care program testing business is strictly prohibited and should be reported to the Crestar

compliance hotline by calling (615) 850-9010.

Clinical Consultants: Physicians and other clinicians authorized to order tests have the services of clinical consultants and toxicologists

available to ensure proper test ordering and answer questions. They may be reached at (615) 850-9010.

Prohibited Referrals: It is the policy of Crestar to comply with all aspects of the laws and regulations governing physician self-referral, most

notably including the federal Stark law. The Stark law’s self-referral ban states that if a financial relationship exists between a physician (or

an immediate family member) and a laboratory (or certain other kinds of healthcare providers), and the relationship does not fit squarely

into one of the law’s exceptions, then (a) the physician may not refer Medicare patients to the laboratory, and (b) the laboratory may not

bill Medicare for services referred by the physician. The kinds of relationships between laboratories and physicians that may be affected by

these laws include the lease or rental of space or equipment and the purchase of medical or other services by a laboratory from a referring

physician.

Financial Assistance Programs: Crestar understands that providing quality patient care has a related cost, which in some situations may be

burdensome for patients and result in some patients avoiding certain necessary services because they are concerned about the expense.

Crestar is committed to delivering the best patient care to all, and to meet this objective has established a financial support program. This

financial support program helps ensure affordable access to Crestar’s services. Patients with special financial needs may be eligible for

support to help defray some of Crestar’s testing costs. Crestar encourages those patients who may not be able to pay fully for Crestar’s

services to contact us for an assessment of eligibility for financial support in accordance with federal guidelines.

rev 20170801

Page 8 of 8