ExoDx Prostate IntelliScore Electronic Order Form
Test ordered
*
ExoDx Prostate IntelliScore
Does Patient need to be contacted regarding insurance coverage and the Patient Assistance program?
Yes
No
Does Patient need Spanish instructions?
Yes
Date Requested
-
Month
-
Day
Year
Date
Ordering Physician Name
*
First Name
Last Name
Ordering Physician Practice Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Ordering physician email
example@example.com
Ordering physicians contact number
*
-
Area Code
Phone Number
Patient Info
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Patient contact number
*
-
Area Code
Phone Number
Patient Address - *NO PO BOXES*
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
ICD 10 DX code
*
R97.20 Elevated PSA
Comments
Does patient meet traditional Medicare coverage guidelines?
*
Yes
No
Patient not covered by traditional Medicare
Please note that this field constitutes as an electronic signature for ordering the ExoDx Prostate IntelliScore test.
Physician Signature
*
Important Reminders
After submitting this form, we'll check your order and we'll contact you if there are any questions.
Collection kit will be sent to patient via FedEx overnight delivery.
Once sample is recieved back by the lab, results are available within 3-5 business days.
Please call 844-Exosome, option 3, then option 2 with any questions
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