Exo mdx At-Home Kit Order Form

Patient Information
Patient Info

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?

Authorization
ICD-10-CM (diagnosis) code:

Other Code
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.

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