Cologuard Order Form – Fill Out and Use This PDF

Cologuard Order Form PDF Details

This requisition document is for healthcare providers who want to order the Cologuard stool-based DNA colorectal cancer screening test. Exact Sciences Laboratories, LLC produces it at 145 E Badger Rd, Suite 100, Madison, WI. The form is available as an editable, printable PDF on ExactLabs.com and collects all the provider, patient, and billing information needed to process the test accurately.

Who should complete the Cologuard requisition

Licensed healthcare providers complete the requisition when they determine the Cologuard test is appropriate for a patient. Eligible patients are adults aged 45 and older at average risk for colorectal cancer. Average risk means the patient has no personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease. Providers confirm patient eligibility in the certification section before submitting.

Sections covered in this form

The requisition is divided into six main sections. Each must be completed accurately to avoid delays in test processing:

• Provider and order information: Captures the healthcare organization name, the ordering provider's NPI number, office phone number, and fax number. It also records the order date and clinical details. The form states that payment availability should not influence medical judgment when ordering the test.
• Diagnostic codes: Lists suggested ICD-10 codes for convenience. The primary code is Z12.11 (encounter for screening for malignant neoplasm of colon). Providers should choose the code that best describes the patient's clinical situation.
• Provider certification: The ordering provider signs to confirm three items: authority to order the test, medical necessity, and patient eligibility for average-risk colorectal cancer screening.
• Patient demographics: Collects the patient's full legal name, date of birth, biological sex, mailing address, and phone number. Accurate details here ensure the lab can match the sample to the correct patient record.
• Insurance and billing details: Providers enter the policyholder name, insurance ID number, group number, and health plan name. Patients can authorize Exact Sciences to bill their insurance directly, or they may choose self-pay. A separate authorization section confirms the patient's billing preference and financial responsibility.
• Patient ethnicity and race: An optional section that captures demographic data for public health reporting purposes only. Completing it is not required to process the order.

How to submit the completed requisition

After completing all required fields, providers can submit the requisition by fax to Exact Sciences at the fax number printed on the form. Electronic submission is also available through EpicCare Link for registered providers. For ordering questions, call 1-844-870-8870.

Tips for filling out the form correctly

Complete all required fields before submitting. Missing provider NPI numbers or incomplete billing information are the most common causes of processing delays. Confirm the patient's insurance coverage before choosing a billing method to reduce claim denials. Double-check that the diagnostic code matches the patient's clinical situation.

Related healthcare forms

Providers handling multiple documentation needs may find the lab requisition form useful for general laboratory test orders. For broader physician documentation, see the medical physician order form. Annual wellness visits may also require the health screening report form.