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
Cologuard® Order Requisition Form and Process | Cologuard® …
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.
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 REQUISITION FORM. EXACT SCIENCES LABORATORIES, LLC . 145 E. Badger Rd, Ste 100, Madison, WI 53713 P: 844-870-8879 | www.exactlabs.com. Fax completed form to 844-870-8875. Healthcare Organization: _____ Provider Name: _____ NPI #: Test Name: Cologuard. Test Description: Stool-based DNA test with hemoglobin
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COLOGUARD®ORDER
PDF (available at exactlabs.com) and print copies for future orders. By ordering Cologuard, I certify that I am a licensed medical professional authorized to order Cologuard. I acknowledge that the test is medically necessary and that the patient is eligible to use Cologuard.
How To Get Cologuard® | Cologuard Patient Site
If you’re 45+ at average risk for colon cancer, there are two easy ways that you can request Cologuard. Simply request it online or talk with your healthcare provider and we’ll deliver your prescribed kit right to your door.
Once you and your healthcare provider have agreed Cologuard is right for you, then it's time to fill out the order form that's found at the end of this guide. You can complete it on your own, or your healthcare
I authorize Exact Sciences Laboratories to obtain reimbursement for Cologuard and to directly contact and collect additional samples from the patient Phone Number: as appropriate.
Please note that most EHR systems allow you to create a test requisition form template to order tests. These steps are provided as a convenience for adding a template to order Cologuard. If you need further assistance please contact your EHR vendor for support.
If you determine Cologuard is right for your patient, please verify the information entered by the patient below before lling out the rest of the form and faxing it to the number provided. To learn more or contact us, visit CologuardTest.com/HCP or call us any time at 1-844-870-8870.
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