Clone of ExoDx Prostate IntelliScore Electronic Order Form

ExoDx Prostate Test Electronic Order Form
Date Requested

MonthDayYear
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*

MonthDayYear
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.

Browse Files

Cancelof
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
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