Wellpath BOP

To submit your patients most recent UDS result, please fill out our secure form. Please get in touch with our team by calling us at 815-473-8626 Monday-Friday between 11AM-7PM EST.
Patient Information
Patient's Name*
Registration Number*
Testing Date and Time*

MonthDayYear

Hour MinutesAM/PM Option
Result*
A positive result for Buprenorphine must be separate from other results
If Positive please provide explanation and next steps
Referrer Information
RRC Name*
RRC State*
RRC Staff Name *
RRC Phone*
Please enter a valid phone number.
RRC Email *
example@example.com
Please include clear photos of test results.*

Cancelof
Notes (optional)
Should be Empty:

Patient Information