Cologuard Order Form PDF Details

The Cologuard Order form serves as a crucial document for healthcare providers who wish to utilize a non-invasive, stool-based DNA test to screen for colorectal cancer in eligible patients. Crafted by Exact Sciences Laboratories, LLC, and located at 145 E Badger Rd, Suite 100, Madison, WI, the form is designed to be both editable and printable from the ExactLabs.com website, ensuring ease of use for providers. It comprehensively gathers provider and order information, including healthcare organization details, provider credentials, and specific order information with an emphasis not to influence medical judgment. Diagnostic codes are provided for convenience, but the form explicitly states that the ordering provider should use the codes that best describe the reason for the test. It includes a certification section for the provider to confirm their authority to order the test, its medical necessity, and the patient’s eligibility. Additionally, it covers patient demographics, insurance/billing information, and authorizations, including a section where the patient can opt for Exact Sciences to bill their insurance directly or choose self-pay. The patient's ethnic and racial background can also be indicated, although this is optional. Furthermore, it outlines the patient's authorization for Exact Sciences Laboratories to handle billing, insurance information, test results, and appeals for reimbursement denials, clearly stating the patient's financial responsibilities. This form bridges the gap between innovative cancer screening technologies and the patients who stand to benefit from them, embodying a commitment to both privacy and accessibility.

QuestionAnswer
Form NameCologuard Order Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescologuard order requisition form, exact sciences fax number, cologuard fax number, exact sciences cologuard order form

Form Preview Example

 

 

 

 

 

 

 

COLOGUARD® ORDER

EXACT SCIENCES LABORATORIES, LLC

 

 

 

 

 

 

 

 

 

REQUISITION FORM

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

 

 

 

 

 

 

 

 

 

 

p: 844-870-8870 | ExactLabs.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stool-based DNA test with hemoglobin immunoassay component

 

NPI: 1629407069 TIN: 463095174

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider & Order Information

Recommended: type all Provider information.

 

 

Editable, printable PDF available at exactlabs.com

 

 

 

 

 

 

 

 

 

 

 

PROVIDER INFORMATION

 

 

 

 

 

ORDER INFORMATION

 

Healthcare Organization Name: _____________________________

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

provider in determining whether this test is right for any particular patient. The

 

 

 

 

 

 

 

 

 

 

 

 

 

 

following codes are listed as a convenience. Ordering practitioners should report

Provider Name: _____________________________________________

the diagnosis code(s) that best describes the reason for performing the test.

ICD-10 Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI #:

 

 

 

 

 

 

 

 

 

 

 

 

 

Z12.11 and Z12.12 (Encounter for screening for malignant

 

 

 

 

 

 

 

 

 

 

 

 

neoplasm of colon [Z12.11] and rectum [Z12.12])

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location Address: __________________________________________

Other(s)____________________________________________________

Certification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip: _____________________________________________

I am a licensed healthcare provider authorized to order Cologuard. This

test is medically necessary and the patient is eligible to use Cologuard.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I will maintain the privacy of test results and related information as

Phone Number: ____________________________________________

required by HIPAA. I authorize Exact Sciences Laboratories to obtain

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): _________________________________

First Name: ______________ Last Name: ______________________

 

 

Home

Mobile

Work

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

 

 

 

 

 

Patient Insurance/Billing Information

Only completion of “Policyholder Name” and “Policyholder DOB” is necessary when

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: ___________________

FRM-3004-05-c February 2019

Fax completed form to 844-870-8875

For Lab Use Only

Sample Collected: __ /__ /_____ Sample Received: __ /__ /_____

How to Edit Cologuard Order Form Online for Free

It is easy to obtain documents making use of our PDF editor. Improving the cologuard referral form form is straightforward if you check out the following steps:

Step 1: Hit the orange "Get Form Now" button on the following website page.

Step 2: At this point, you may change your cologuard referral form. The multifunctional toolbar permits you to add, eliminate, modify, highlight, and also undertake many other commands to the text and areas inside the form.

If you want to prepare the template, type in the information the platform will require you to for each of the appropriate segments:

example of blanks in exact sciences cologuard order form

Fill in the PATIENT ETHNICITY AND RACE The, Is your patient of Hispanic or, Yes, Please mark one or more to, White, Black or AfricanAmerican, Asian, Native Hawaiian or other Pacific, American Indian or Alaska Native, Patient InsuranceBilling, Only completion of Policyholder, Does patient wish Exact Sciences, Yes complete below, No patient will selfpay, and Policyholder Name Policyholder areas with any data that will be requested by the program.

exact sciences cologuard order form PATIENT ETHNICITY AND RACE The, Is your patient of Hispanic or, Yes, Please mark one or more to, White, Black or AfricanAmerican, Asian, Native Hawaiian or other Pacific, American Indian or Alaska Native, Patient InsuranceBilling, Only completion of Policyholder, Does patient wish Exact Sciences, Yes complete below, No patient will selfpay, and Policyholder Name Policyholder fields to fill out

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