Clone of ExoDx Prostate IntelliScore Electronic Order Form

If you have a portal account, a copy of your portal data has been migrated to the new mdxhealth portal. While the current portal is still functional, we encourage you to start using the newer platform for an improved experience.

To get started, please check your inbox for an activation email from portal@mdxhealth.com. The new portal is at https://mdxhealthsecure.com/ and includes all previous features, plus new capabilities like FedEx pickup scheduling. You'll also be able to order all other mdxhealth urology products, including Confirm mdx, GPS mdx, and Resolve mdx, all in one place.

If you can't find your activation email, or do not have a portal account and need to apply for one, please contact cs@mdxhealth.com | 866‑259‑5644 (M–F, 5am–5pm PT).

Date Requested

Date

Ordering Provider's Name

First NameLast Name

Ordering Provider's NPI Number

Ordering Provider Practice Address

Street Address

Street Address Line 2

CityState

Zip Code

Ordering Provider Email

example@example.com

Ordering Provider Contact Number

Area CodePhone Number

Ordering Provider Fax Number

Area CodePhone Number

Patient Info

First NameLast Name

Patient Date of Birth

Date

Patient Cell Phone Number

Area CodePhone Number

Alternative Patient Contact Number

Area CodePhone Number

Type of Phone Number

Patient Address - *NO PO BOXES*

Street Address

Street Address Line 2

CityState

Zip Code

Does Patient Need Spanish Instructions?

ICD 10 DX Code

Other

This Laboratory Developed Test was developed, and its performance characteristics determined by Exosome Diagnostics, Inc. The laboratory is regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high-complexity clinical testing. This test has not been cleared or approved by the U.S. Food and Drug Administration.

I attest that this form constitutes a certification of medical necessity. I am familiar with the parameters of use for this test, including protocols and guidelines for prostate cancer as issued by the National Comprehensive Cancer Network (NCCN). I have obtained consent from my patient for Exosome Diagnostics, Inc. to release the test results and medical information to the patient's insurance carrier as part of the coverage and reimbursement process.

Type Provider Signature

Please attach any clinical documentation, relevant medical history or other attachments.

Browse Files

Important Reminders

Orders MUST be submitted through this link. We DO NOT accept printed and faxed orders for At-Home kits
After submitting this form, we will check your order and contact you if there are any questions
Collection kit will be sent to patient via FedEx Ground delivery
Once sample is received back by the lab, results are available within 3-5 business days
Please call 866-259-5644 or email exodx@mdxhealth.com with any questions