Step 1 of 520%ColoSense Order Form Stool-based RNA test with hemoglobin immunoassay component Complete all required sections below. Ordering provider MUST complete and sign this requisition form to activate the order. If you would rather download the requisition and fax it to us, please download the ColoSense Test Requisition and Statement of Medical Necessity form . Complete all required fields on the form and fax it to 314-408-3864. For questions, please contact ColoSense Customer Support at 800-305-8299.Patient InformationThis field is hidden when viewing the formPatient Name(Required) First Middle Last Patient First Name(Required)Patient Middle NamePatient Last Name(Required)Patient Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code This field is hidden when viewing the formPatient Address - SFPatient Mobile Phone(Required)Patient Email Patient Sex(Required)FemaleMaleNot GivenPatient Date of Birth(Required) MM slash DD slash YYYY Patient Language Preference(Required)EnglishSpanishOtherOther Language Preference(Required)This field is hidden when viewing the formPatient Language Preference - SFPatient RaceAsianBlack or African AmericanWhiteHispanicAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderOtherNot IndicatedIs your patient of Hispanic or Latino descent?YesNoPatient Consent By checking this box, I confirm that Patient has consented to calls or text messages from Geneoscopy concerning general CRC updates, reminders to screen again for CRC, and other healthcare and general account information.NOTE: If this box is not checked, Geneoscopy will still be able to provide reminders / notifications to Patient via phone call or text message about their current ColoSense order or test results. If Patient wishes to receive no communications, they may contact 800-305-8299 to update their preferences.Patient Payment InformationPayment Type(Required)Client BillInsuranceSelf-PayPatient Insurance InformationPatient's Insurance CardPlease upload a copy of the patient’s insurance card (front/ back) OR their demographic sheet with insurance details.Max. file size: 300 MB.If you prefer not to attach a file, please check the box to enter their insurance information below. This field is hidden when viewing the formUntitledInsurance TypePrivate InsuranceMedicareMedicaid - North CarolinaMedicaid - OhioMedicaid - GeorgiaMedicaid - KentuckyMedicaid - LouisianaMedicaid - MaineMedicaid - MissouriMedicaid - MontanaMedicaid - New MexicoMedicaid - TennesseeCompany and Plan NameThis field is hidden when viewing the formInsurance Type - Company and Plan Name SFThis field is hidden when viewing the formFile UploadedYesNoPolicy Holder Name First Middle Last Policy Holder SexFemaleMaleNot GivenPolicyholder Date of Birth MM slash DD slash YYYY Insurance Group NumberInsurance Member ID NumberRelationship to PatientSelfSpouseChildOtherRelationship to Patient OtherThis field is hidden when viewing the formRelationship to Patient Other - SFAccount InformationHealthcare Organization Name(Required)Phone Number(Required)Secure Fax Number(Required)Secure Fax Number must be provided to receive results.Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code This field is hidden when viewing the formAccount Info Address - SFProvider InformationProvider NPI Number(Required)Enter 10 digit numeric identifierProvider Name(Required) First Last Provider Email(Required) Order InformationICD-10 Code(Required)Z12.11 and Z12.12 (Encounter for screening for malignant neoplasm of colon [Z12.11] and rectum [Z12.12]OtherOther ICD-10 Code(Required)This field is hidden when viewing the formICD-10 Code - SFProvider Signature I am a licensed healthcare provider authorized to order ColoSense. This test is medically necessary and the Patient is eligible to use ColoSense. I confirm that the Patient is asymptomatic, at the average risk of developing Colorectal Cancer (CRC), and has not been screened by another CRC screening method within the past year. I agree to provide a copy of relevant clinical history and medical records in order to support a request from a health plan. I will maintain the privacy of test results and related information as required by HIPAA. I authorize Geneoscopy, Inc. to obtain reimbursement for ColoSense and to directly contact and collect additional samples from the Patient as appropriate.This field is hidden when viewing the formCertification I am a licensed healthcare provider authorized to order ColoSense. This test is medically necessary and the Patient is eligible to use ColoSense. I confirm that the Patient is asymptomatic, at the average risk of developing Colorectal Cancer (CRC), and has not been screened by another CRC screening method within the past year. I agree to provide a copy of relevant clinical history and medical records in order to support a request from a health plan. I will maintain the privacy of test results and related information as required by HIPAA. I authorize Geneoscopy, Inc. to obtain reimbursement for ColoSense and to directly contact and collect additional samples from the Patient as appropriate.Provider Printed Name(Required)Signature(Required)This field is hidden when viewing the formSignature IMGThis field is hidden when viewing the formSignature Download
