Cologuard Order Form PDF Details

The Cologuard Order Form is a form that is used to order the testing from the company, which provides it for those who are not insured. It can be purchased by anyone and should be ordered through the website of the company before sending in an order. The Cologuard Order Form can also be found by visiting any local pharmacy or doctor's office. The form consists of personal information about the person ordering it, including any known medical conditions they may have as well as their name, date of birth, contact information and social security number. After this has been completed, there will then need to be two stool samples collected on separate days that will then need to be sent back to LabCorp for analysis.

You can find info about the type of form you want to prepare in the table. It will show you how much time it takes to finish cologuard order form, exactly what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameCologuard Order Form
Form Length1 pages
Fillable?Yes
Fillable fields38
Avg. time to fill out7 min 55 sec
Other namescologuard form, cologuard test order form, exact sciences fax number, cologuard fax number

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 requisition 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 requisition 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 cologuard form pdf

Fill in the ShippingAddress, BillingAddress, SameasShipping, CityStateZip, Yes, White, BlackorAfricanAmerican, Asian, AmericanIndianorAlaskaNative, PatientInsuranceBillingInformation, Yescompletebelow, Nopatientwillselfpay, Self, Spouse, and Other areas with any data that will be requested by the program.

cologuard form pdf ShippingAddress, BillingAddress, SameasShipping, CityStateZip, Yes, White, BlackorAfricanAmerican, Asian, AmericanIndianorAlaskaNative, PatientInsuranceBillingInformation, Yescompletebelow, Nopatientwillselfpay, Self, Spouse, and Other fields to fill out

Step 3: Press the "Done" button. Now, you may export your PDF file - upload it to your electronic device or forward it through electronic mail.

Step 4: It's going to be more convenient to save duplicates of the form. You can rest assured that we won't display or read your details.

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