ExoDx Prostate IntelliScore Electronic Order Form

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 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
Type of phone number

Cell phone Home phone Work Phone
Alternative Patient contact number

Area Code Phone Number
Type of phone number

Cell Phone Home Phone Work Phone
Patient Address - *NO PO BOXES* *

Street Address

Street Address Line 2

City 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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