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I authorize Exact Sciences Laboratories to obtain reimbursement for Cologuard and to directly contact and collect additional samples from the patient Phone Number: as appropriate.
Take the first step to getting your Cologuard ® order today. It’s an effective, noninvasive test that requires no prep.
Download a Cologuard® test order requisition form as a PDF, explore our electronic ordering options, or receive easy access to patient information and results. For adults 45+ At Avg. Risk. Rx Only.
If you’re 45+ at average risk for colon cancer, there are two easy ways that you can request Cologuard. Simply request it online or talk with your healthcare provider and we’ll deliver your prescribed kit right to your door.
COLOGUARD® ORDER REQUISITION FORM. EXACT SCIENCES LABORATORIES, LLC. 145. E. Badger Rd, Ste 100, Madison, WI 53713 P: 844-870-8879 | www.exactlabs.com. Fax completed form to 844-870-8875. Provider & Order Information. Recommended: type all Provider information. Editable, printable PDF available at exactlabs.com. PROVIDER INFORMATION.
Cologuard is intended for the qualitative detection of colorectal neoplasia associated DNA markers and for the presence of occult hemoglobin in human stool. A positive result may indicate the presence of colorectal cancer (CRC) or advanced adenoma (AA) and should be followed by colonoscopy.
Z12.11 and Z12.12 (Encounter for screening for malignant neoplasm of colon [Z12.11] and rectum [Z12.12]) I am a licensed healthcare provider authorized to order Cologuard. This test is medically necessary and the patient is eligible to use Cologuard.
GI TO PATIENT COMMUNICATION TEMPLATE: Patient Cologuard Order Letter From Provider (M-US-CG-03574) Indications and Important Risk Information Cologuard is intended to screen adults 45 years of age and older who are at average risk for colorectal cancer by detecting certain DNA markers and blood in the stool. Do not use if you
Please note that most EHR systems allow you to create a test requisition form template to order tests. These steps are provided as a convenience for adding a template to order Cologuard. If you need further assistance please contact your EHR vendor for support.
Order a Cologuard Test by Fax. Fill out this order form entirely and fax it to Exact Sciences at 1-844-870-8875.