Get Frm-3006-01-c

Filling out the FRM-3006-01-c form online is a straightforward process that facilitates the ordering of Cologuard tests. This guide provides step-by-step instructions to ensure that users can easily complete the form accurately.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Enter the provider information. Fill in the healthcare organization's name, location address, provider name, city, state, zip code, phone number, NPI number, and secure fax number. If an NPI number is not available, provide the DEA number.
3. In the test information section, specify the test name as Cologuard and include the ICD10 code (Z12.11 and Z12.12) alongside any other applicable diagnosis codes.
4. Obtain the ordering provider's signature and date of order to validate the request for the test.
5. Complete the patient assignment of benefits notice by obtaining the patient's signature and date, indicating authorization to bill insurance and disclose health records.
6. Provide patient information including patient ID/MRN, first and last name, date of birth (DOB), sex, primary phone number (home, mobile, or work), optional email address, and language preference.
7. Fill in the patient address section to include the shipping address and billing address. If they are the same, indicate accordingly.
8. Complete patient insurance/billing information, including policyholder name, DOB, relationship to the patient, type of insurance, insurance carrier/program, subscriber ID/policy number, and group number.
9. After filling out all sections, review the information for accuracy, save the changes, and download, print, or share the completed form.

Complete your documents online today for efficient processing.