Urine Drug Monitoring Request Form

Please complete the form below to submit a claimant for pain medication monitoring with Ameritox. This information will be reviewed and an Ameritox representative will be in touch with you no later than one business day from receipt of your submission.

* Required fields

Requestor(s) Information:


ext.

Requestor 2:

* Phone
ext.

Claimant Information:

Physician Information:


ext.

Opioid Therapy

Yes   No