Fillable Form 3.: SUBSTANCE ABUSE PREVENTION AND CONTROL DRUG (County of Los Angeles / Internal Services Department)

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Form 3.: SUBSTANCE ABUSE PREVENTION AND CONTROL DRUG (County of Los Angeles / Internal Services Department)

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U.S.A. forms for County of Los Angeles / Internal Services Department

BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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SUBSTANCE ABUSE PREVENTION AND CONTROL
DRUG TESTING FORM
DRUG TESTING INFORMATION
1. Date of drug test: 2. Time of drug test:
3.
Testing method:
Point
of
Care Testing or Lab-Based Testing
4.
Type of drug test: Urine Blood Saliv
a Hair
Sweat Other
5. Type of panel (e.g. 5 panel):
PATIENT INFORMATION
6. Name (Last, First, and Middle):
7.
Date of Birth (MM/DD/YYYY):
8. Medi-Cal or MHLA Number:
9. Address:
10. Gender:
11. Preferred Language:
12. Race/Ethnicity:
13. Phone Number:
Okay to Leave a Message?
Yes No
PROVIDER AGENCY
14. Name:
16. Phone Number:
17. Address:
19. Email:
DRUG TEST RESULT
Substance Positive Result Concentration / Level for Lab Test
Alcohol
Amphetamines
THC
Cocaine
Opiates
Phencyclidine (PCP)
Barbiturates
3,4-Methylenedioxymethamphetamine
(MDMA)
Benzodiazepines
Methadone
Revised 06/21/2017 2
Substance Positive Result Concentration / Level for Lab Test
Buprenorphine
Oxycodone, Hydrocodone,
Hydromorphone, Oxymorphone
Meperidine
Tramadol
Fentanyl
Ketamine
Naloxone
Nalbuphine
Butorphanol, Pentazocine
Propoxyphene
20. Provider Name:
21. Signature:
22. Date:
This confidential information is provided to you in accord with State and Federal laws and regulations including but not
limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
EXTERNAL SAPC REVIEW This section will include communication between SAPC and the agency/provider.
Comments:
Assigned Staff: __________________ Reviewed by: _____________ Signature: _______________ Date: ______________
INTERNAL SAPC USE ONLY This section is reserved for internal SAPC use only.
Comments:
Assigned Staff: __________________ Reviewed by: _____________ Signature: _______________ Date: ______________
Revised 06/21/2017 3
DRUG TESTING FORM INSTRUCTIONS
DRUG TESTING INFORMATION
1. Enter the date of the drug test (mm/dd/yyyy)
2. Enter the time of the drug test
3. Enter the testing method i.e. Point of Care Testing (POCT) or Lab Based Testing.
4. Enter the type of drug test
5. Enter the type of drug test panel (for example a 5 panel drug test)
PATIENT INFORMATION
6. Enter the patient name in the order of last name, first name, and middle name.
7. Enter the patient date of birth.
8. Enter the patient Medi-Cal or My Health LA (MHLA) number. If the number is not known, leave
the space blank.
9. Enter the patient address.
10. Enter the patient gender
11. Enter the patient preferred language
12. Enter the patient race/ethnicity
13. Enter the patient phone number. Check box to indicate if it is okay to leave a message at this
phone number.
PROVIDER AGENCY
14. Enter the agency name
15. Enter the contact person
16. Enter the phone number
17. Enter the address
18. Enter the fax
19. Enter the email
DRUG TEST RESULTS: Please indicate positive or negative drug results. If available, please enter the
drug level or concentration.
20. Enter the provider name
21. Enter the provider signature
22. Enter the date
EXTERNAL SAPC REVIEW
This section will include communication between SAPC and the agency/provider
INTERNAL SAPC USE ONLY
This section is reserved for internal SAPC use only.
SUBMIT THE FORM TO:
Fax: (323) 725-2045
Phone: (626) 299-4193
FOR ADDITIONAL SAPC DOCUMENTATION PLEASE SEE
http://publichealth.lacounty.gov/sapc/NetworkProviders/Forms.htm
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Form 3.: SUBSTANCE ABUSE PREVENTION AND CONTROL DRUG (County of Los Angeles Internal Services Department)

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Completed 31 May 2021

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