Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editing software.
2. Begin by providing patient information. Fill in the patient's sex (M, F, or Unknown), telephone number, email address, and residential address, including city, state, and zip code.
3. In the acknowledgement section, read the authorization statements carefully. Choose to authorize or not authorize Progenity to retain and use de-identified specimen and test data. Make sure to sign and print the patient's or guardian's name below the signature line.
4. Indicate the date (MM/DD/YY) of filling out the form and select the method of specimen collection from the options provided.
5. Complete the ordering clinician information section, including the clinician's name, date of birth (MM/DD/YYYY), clinic name, telephone number, fax number, address, city, state, zip code, and clinician NPI number.
6. Under billing information, provide the name of the insured individual, member ID, insurance company name, and attach a copy of the insurance card (front and back) to the form.
7. If necessary, report any pre-authorization referrals and indicate the billing preference (to bill the patient or ordering clinician).
8. Fill in the specimen information, including the date collected (MM/DD/YY), time collected, and the person who collected the sample.
9. Detail the tests requested and relevant clinical indications, selecting all appropriate options from the list provided.
10. Report any ICD-10 diagnostic codes you believe apply, marking all that are relevant.
11. Provide any additional clinical information, including a history of clinical conditions or relevant family history.
12. Review the completed form for accuracy and clarity before saving your changes, downloading, or printing the document for submission.

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