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    Provider & Order Information: Fax Completed Form To 844-870-8875

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    Brian

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    Provider & Order Information: Fax Completed Form To 844-870-8875

    Uploaded by

    Brian
    198 views1 page

    Original Title

    FRM-3006-01-c_F_CologuardTest_HCP-HTO

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    198 views1 page

    Provider & Order Information: Fax Completed Form To 844-870-8875

    Uploaded by

    Brian

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    COLOGUARD® ORDER EXACT SCIENCES LABORATORIES, LLC

    145 E Badger Rd, Ste 100, Madison, WI 53713


    REQUISITION FORM p: 844-870-8870 | ExactLabs.com
    Stool-based DNA test with hemoglobin immunoassay component NPI: 1629407069 TIN: 463095174
    Recommended: type all Provider information.
    Provider & Order Information Editable, printable PDF available at exactlabs.com
    PROVIDER INFORMATION ORDER INFORMATION

    This section is not intended to influence the medical judgment of an ordering


    Healthcare Organization Name: _____________________________ provider in determining whether this test is right for any particular patient. The
    following codes are listed as a convenience. Ordering practitioners should report
    the diagnosis code(s) that best describes the reason for performing the test.
    Provider Name: _____________________________________________
    ICD-10 Code:

    NPI #: Z12.11 and Z12.12 (Encounter for screening for malignant


    neoplasm of colon [Z12.11] and rectum [Z12.12])
    Other(s)____________________________________________________
    Location Address: __________________________________________
    Certification
    I am a licensed healthcare provider authorized to order Cologuard. This
    City, State, Zip: _____________________________________________ test is medically necessary and the patient is eligible to use Cologuard.
    I will maintain the privacy of test results and related information as
    required by HIPAA. I authorize Exact Sciences Laboratories to obtain
    Phone Number: ____________________________________________ reimbursement for Cologuard and to directly contact and collect
    additional samples from the patient as appropriate.
    Secure Fax Number*: _______________________________________ _____________________________________________________________
    *To receive results for this order, please provide secure FAX number only Ordering Provider Signature Date of Order

    Patient Demographics Attach a copy of the front & back of primary and/or secondary insurance cards.

    Patient ID/MRN: ____________________________________________ Phone Number (required): _________________________________


    Home Mobile Work
    First Name: ______________ Last Name: ______________________
    Language Preference (optional):____________________________
    DOB (mm/dd/yyyy): _______________ Sex: Male Female

    Shipping Address: __________________________________________ Billing Address: ____________________________________________


    Same as Shipping
    ___________________________________________ ____________________________________________

    City, State, Zip: ___________________________________________ City, State, Zip: ____________________________________________


    PATIENT ETHNICITY AND RACE The completion of this section is optional.

    Is your patient of Hispanic or Latino origin or descent? Yes No


    Please mark one or more to indicate your patient’s race:
    White Black or African-American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native
    Only completion of “Policyholder Name” and “Policyholder DOB” is necessary when
    Patient Insurance/Billing Information attaching a copy of the front & back of primary and/or secondary insurance cards.

    Does patient wish Exact Sciences to bill their insurance? Yes (complete below) No (patient will self-pay)

    Policyholder Name: ____________________ Policyholder DOB: ____________ Relationship to patient: Self Spouse Other

    Primary Insurance Carrier: _________________________ Type: Private Medicare Medicare Advantage Medicaid Tricare

    Claims Submission Address: ________________________________________________________________________________________________

    Subscriber ID/Policy Number: __________________ Group Number: ______________________ Plan: _______________________________

    Prior-Authorization Code (if available): ________________________________________________

    PATIENT AUTHORIZATIONS, ASSIGNMENT OF BENEFITS (AOB) & FINANCIAL RESPONSIBILITIES


    I authorize Exact Sciences Laboratories (Exact) to bill my insurance/health plan and furnish them with my Cologuard order information, test results, or other information requested
    for reimbursement. I assign all rights and benefits under my insurance plans to Exact and authorize Exact to appeal and contest any reimbursement denial, including in any
    administrative or civil proceedings necessary to pursue reimbursement. I authorize all reimbursements to be paid directly to the laboratory in consideration for services performed.
    I understand that I am responsible for any amount not paid, including amounts for non-covered services or services determined by my plan to be provided by an out-of-network
    provider. I further understand that if I am a Medicaid enrollee in a state where Exact is enrolled as a Medicaid provider, Exact will accept as payment in full the amounts paid by the
    Medicaid program, plus any deductible, coinsurance or copayment which may be required by the Medicaid program to be paid by me.

    Patient Signature: _________________________________________________________________ Date: ___________________

    For Lab Use Only


    FRM-3004-05-c Fax completed form to 844-870-8875 Sample Collected: __ /__ /_____ Sample Received: __ /__ /_____
    February 2019

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