Get Oncotype Dx Requisition Form

Completing the Oncotype Dx Requisition Form is a vital step for assessing the appropriate treatment for patients diagnosed with breast cancer. This guide will walk you through the process of accurately filling out the form online, ensuring that all necessary information is provided to facilitate efficient claims processing.

Follow the steps to complete the Oncotype Dx requisition form online.

1. Click ‘Get Form’ button to obtain the requisition form and open it for editing.
2. Start by entering the prescriber information in the designated fields. Input the physician's name, provider ID or tax ID (required if located out of state), and the patient’s BCBSNC ID. Additionally, provide the contact person's name, practice name, phone number, and address.
3. Next, navigate to the patient information section. Fill in the patient's name, their date of birth, and the practice fax number. Include the city, state, and ZIP code of the patient’s residence.
4. Document the date of breast cancer diagnosis in the specified field. Ensure accuracy as it is crucial for the claims process.
5. Respond to the coverage criteria questions accurately. For each question regarding the patient's condition and treatment eligibility, check 'YES' or 'NO' as appropriate.
6. Indicate whether the test is being ordered by the physician who will administer chemotherapy or by the treating surgeon. Check the correct box and provide supporting documentation if necessary.
7. In the physician attestation section, review the statements provided, then sign and date the form where indicated. Ensure that an original signature is used, as stamped signatures are not accepted.
8. Finally, submit the completed form by faxing it to the appropriate number based on the patient's insurance provider, as specified at the bottom of the form. Ensure you keep a copy for your records.

Complete your Oncotype Dx Requisition Form online today to ensure timely processing and care for your patient.