Clone of ExoDx Prostate IntelliScore Electronic Order Form

Date Requested

Date

Ordering Physician Name*

First NameLast Name

Ordering Physician Practice Address*

Street Address

Street Address Line 2

CityState

Zip Code

Ordering Physician Email

example@example.com

Ordering Physicians Contact Number*

Area CodePhone Number

Ordering Physicians 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

Home PhoneWork Phone

Patient Address - *NO PO BOXES* *

Street Address

Street Address Line 2

CityState

Zip Code

Does Patient Need Spanish Instructions?

YesNo

ICD 10 DX Code *

R97.20 Elevated PSAOther

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.*

Test Ordered: ExoDx Prostate Test

Type Physician Signature*

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

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Important Reminders

Orders MUST be sumitted 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 844-Exosome, option 4 with any questions