Get Cologuard Order Form

Filling out the Cologuard Order Form online is a straightforward process that helps healthcare providers order this stool-based DNA test. This guide will walk you through each section of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to complete the Cologuard Order Form online.

1. Press the ‘Get Form’ button to access the Cologuard Order Form in an editable format.
2. Begin by entering the provider information. This includes the healthcare organization name and the provider's full name. It's recommended to enter all details as accurately as possible.
3. Complete the order information section by providing the ICD-10 codes relevant to the test. Ensure you include the diagnosed codes (Z12.11 and Z12.12) for screening related to malignant neoplasms of the colon and rectum.
4. Fill in your National Provider Identifier (NPI) number, location address, city, state, zip code, and both phone and secure fax numbers. The secure fax number is required for receiving test results.
5. Provide the patient demographics, entering their ID or medical record number (MRN), full name, date of birth, and preferred phone number for contact. Indicate the shipping address and utilize the option to keep the billing address the same if applicable.
6. If desired, mark the patient's ethnicity and race, which is optional. This section can provide additional context for the patient's background.
7. In the patient insurance/billing information section, specify if the patient wishes for Exact Sciences to bill their insurance. If yes, include the policyholder's name, date of birth, and relationship to the patient.
8. Fill out the primary insurance carrier details and any other necessary information about the insurance, including policy numbers and plan types.
9. In the patient authorizations, assignment of benefits, and financial responsibilities section, the patient should sign and date the form, authorizing Exact Sciences to bill insurance and communicate directly for reimbursement.
10. Once you have completed all sections, review the form for accuracy. Save your changes, and if needed, download, print, or share the completed form. Finally, fax the completed form to the designated number.

Complete your documents online and ensure accurate submissions for timely processing.