COLOGUARD® ORDER REQUISITION FORM PROVIDER INFORMATION ORDER INFORMATION 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
How to Get a Cologuard® Test | Collected at Home, Tested in the Lab If you’re 45+ and at average risk for colon cancer, learn how to order the Cologuard test — either online or through your health care provider Either way, we’ll deliver your prescribed kit right to your door
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Laboratories | Exact Labs Cologuard® is an FDA-approved, noninvasive multi-target stool DNA test for colorectal cancer screening The performance characteristics of Cologuard were established in a prospective, multi-site, point-in time study (NCT01397747) of average risk adults ages 50-84
HERE S WHAT TO DO WITH YOUR CUSTOMIZED ORDER FORM. - svimed. com CUSTOMIZED ORDER FORM 1 Print or Save this PDF le 2 Take the printed copy to your healthcare provider or email the PDF le to them 3 Talk to your healthcare provider about whether or not Cologuard is right for you 4 If your healthcare provider decides Cologuard is right for you, ask them to complete the order form on page 2
Cologuard Test Order Requisition Form - Horizon BCBSNJ Ordering practitioners should report the diagnosis code(s) that best describes the reason for performing the test Z12 11 and Z12 12 (Encounter for screening for malignant neoplasm of colon [Z12 11] and rectum [Z12 12]) I am a licensed healthcare provider authorized to order Cologuard
COLOGUARD ORDER EXACT SCIENCES LABORATORIES, LLC REQUISITION FORM Order I authorize Exact Sciences Laboratories (Exact) to bill my insurance health plan furnish them with my Cologuard order information, test results, or other information requested for reimbursement
Cologuard® Order Requisition Form and Process | Cologuard® For HCPs Download a Cologuard® test order requisition form as a PDF, explore our electronic ordering options, or receive easy access to patient information and results For adults 45+ At Avg Risk Rx Only See Risk Info
Cologuard® and Cologuard Plus™ Colon Cancer Screening Tests | Collected . . . Quickly navigate the next steps of your Cologuard journey after you’ve ordered your kit Effective, noninvasive colon cancer screening that requires no prep — just send back your sample to us for testing Request your Cologuard® test today Already have your at-home collection kit?
COLOGUARD REQUISITION FORM - boynton. umn. edu 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 required by HIPAA I authorize Exact Sciences Laboratories to obtain reimbursement for Cologuard and to directly contact and collect