Blank Cologuard Order Template

What is the Cologuard Order form used for?

The Cologuard Order form is designed for healthcare providers to request the Cologuard test, which is a stool-based DNA test that helps screen for colorectal cancer. The test also includes a hemoglobin immunoassay component. This order form collects necessary provider and patient information to process the test accurately.

Who is eligible to complete the Cologuard Order form?

The form must be completed by a licensed healthcare provider who is authorized to order the Cologuard test. It is essential that the provider determine whether the test is appropriate for the specific patient based on their medical history and risk factors.

What information is required on the Cologuard Order form?

The form requires various details, including the healthcare organization name, provider name and NPI number, and patient demographics such as date of birth, sex, and contact information. Additionally, insurance details need to be provided if the patient wishes to have testing billed to their insurance carrier.

How should I submit the Cologuard Order form?

Completed Cologuard Order forms should be faxed to Exact Sciences Laboratories at 844-870-8875. It is important to ensure that all information is accurate to avoid delays in processing.

What are the patient's responsibilities regarding insurance and billing?

Patients must authorize Exact Sciences to bill their insurance for the test. They are responsible for any costs not covered by their plan, including potential out-of-pocket expenses. If the patient is a Medicaid enrollee, Exact will accept the Medicaid payments as full payment, along with any required deductibles or copayments.

How is patient privacy protected through the Cologuard Order form?

The provider signing the order form certifies that they will maintain the confidentiality of the patient's test results and related information in accordance with HIPAA regulations. This ensures that sensitive patient information is handled securely throughout the testing process.

1. Inconsistent Provider Information: Failing to provide complete and accurate information about the healthcare provider can lead to delays. Ensure the provider's name, organization, and contact details are correctly filled out.

2. Missing ICD-10 Codes: Not including the relevant diagnosis code(s) for the test may result in complications with insurance processing. Take care to select the appropriate codes, such as Z12.11 or Z12.12.

3. Invalid or Missing Signature: Forgetting to sign the order form or providing an illegible signature can delay the entire process. Remember that the signature is necessary to confirm authorization to order the Cologuard test.

4. Incomplete Patient Demographics: Provide full patient information, including date of birth and contact numbers. Leaving sections blank can hinder communication and processing.

5. Insurance Information Errors: Incorrect details in the insurance section, such as the policy number or insurance carrier, might lead to reimbursement complications. Double-check these details before submission.

6. Neglecting Patient Authentications: Overlooking the necessary patient authorizations and financial agreements might affect the billing process. Ensure all required authorizations are filled out accurately.

Along with the Cologuard Order form, several other forms and documents are commonly used in the process of testing and billing for Cologuard. Each document serves a specific purpose to ensure accurate communication and compliance with healthcare regulations.

• Patient Information Form: This document collects essential personal details about the patient, such as their name, date of birth, contact information, and insurance details. It ensures that the laboratory has accurate information for processing the test and billing.
• Insurance Verification Form: This form is used to confirm the patient's insurance coverage and eligibility. It includes information about the insurance policyholder and the specifics of the patient’s coverage, which is critical for reimbursement.
• Consent for Treatment Form: This document secures the patient’s consent for the testing process. It outlines the nature of the test, potential risks, and the patient’s rights, ensuring that they are informed before proceeding.
• Authorization for Release of Information: This form grants permission for the laboratory to share the test results with other healthcare providers or entities involved in the patient's care. It plays a crucial role in maintaining continuity of care and patient privacy.
• Payment Authorization Form: This document allows the laboratory to charge the patient’s insurance or credit card directly for any applicable fees. It ensures that billing procedures are followed in accordance with the patient’s financial agreements.

Each of these documents plays a vital role in facilitating a smooth testing process and ensuring compliance with healthcare regulations. Having them completed accurately can help avoid delays in testing and billing, paving the way for timely patient care.

The Cologuard Order form shares similarities with a standard medical prescription form, which serves as a document that physicians provide to pharmacies to dispense medication. Both documents require identification of the healthcare provider and the patient, ensuring that essential details like names, addresses, and contact information are accurately filled out. Just like the Cologuard form, a medical prescription includes sections for the provider's signature and date, underscoring the importance of the medical professional's authorization for treatment. Additionally, both forms often have an insurance information section to facilitate potential reimbursement processes for the services rendered.

Another document closely related to the Cologuard Order form is a referral form used in healthcare settings when a patient needs to see a specialist. Referral forms, like the Cologuard form, are critical in outlining the patient's information and the specific services required. These forms usually include sections for the referring provider’s details and the reason for the referral, much like how the Cologuard form outlines the test being requested. Both documents help in ensuring that all necessary information flows smoothly between healthcare providers and that patient care is effectively coordinated.

The patient intake form is an additional document that relates to the Cologuard Order form. Both documents collect essential information about the patient, including demographics, insurance details, and medical history. Patient intake forms often request similar identifiers such as the patient's name, date of birth, and contact details. They also serve as a means of consent where required, just as the Cologuard form seeks the patient’s authorization for testing. By collecting this information upfront, both forms aim to streamline the process of patient care and ensure that healthcare providers have access to vital data.

Informed consent forms also share commonalities with the Cologuard Order form. Such forms are essential for detailing the procedure that a patient is about to undergo, including potential risks and benefits, thereby ensuring the patient is fully aware. Both types of forms require the patient’s signature to acknowledge understanding and agreement. While the Cologuard form focuses on approval for a specific test, informed consent forms might cover a broader range of medical procedures, yet both emphasize the necessity of transparency in the patient-provider relationship.

Lastly, the insurance claim form exhibits similarities with the Cologuard Order form, particularly in terms of processing payments for medical services. Both documents necessitate detailed information on the patient’s insurance provider, including policy numbers and the nature of the services rendered. The Cologuard form includes a section for the provider to authorize billing, which aligns with the purpose of an insurance claim form to seek reimbursement post-service. Both documents are essential in navigating the often-complex insurance landscape, ensuring that financial matters are addressed appropriately within the healthcare system.

When filling out the Cologuard Order form, there are important considerations to ensure accuracy and compliance. Below are ten do's and don'ts to guide you through the process.

• Do type all provider information clearly.
• Do ensure that the patient’s demographics are completely filled out.
• Do provide a secure fax number to receive test results.
• Do attach both the front and back of the insurance cards.
• Do confirm that the ordering provider signs and dates the form.

• Don't leave any required fields blank.
• Don't forget to check the patient’s insurance billing preference.
• Don't write in illegible handwriting; always type to prevent errors.
• Don't mix up the primary and secondary insurance information.
• Don't assume that optional sections can be ignored; verify their necessity.

Understanding the Cologuard order form can be challenging. Here are 10 common misconceptions about it, along with clarifications to help clear things up.

• Anyone can fill out the order form. Only licensed healthcare providers are authorized to order Cologuard tests.
• The test can be ordered without patient consent. Patients must sign the authorization to allow their information to be shared with insurance companies.
• Cologuard is free for all patients. Depending on insurance coverage, patients may face out-of-pocket costs.
• All insurance plans cover Cologuard. Not all insurers will cover the test, and patients should check with their plans.
• The order form is the same for every patient. Each order form should be filled out with specific patient and provider information.
• The gender and ethnicity sections are mandatory. Completing these sections is optional and not required to process the order.
• There is no need for a secure fax number. A secure fax number is necessary to receive test results confidentially.
• Insurance information is not important. Accurate insurance details are crucial for billing purposes and processing the order.
• The order form can be handwritten. It is recommended to type the information for clarity, though handwritten forms are still accepted.
• The form guarantees that Cologuard will be approved by insurance. Submitting the order form does not guarantee reimbursement or approval; it simply begins the process.

When filling out and using the Cologuard Order form, consider the following key takeaways:

• Complete Provider Information: Provide all necessary details about the healthcare organization and practitioner. This ensures clarity and correct processing.
• Specify Diagnosis Codes: Utilize the appropriate ICD-10 codes, such as Z12.11 and Z12.12, to justify the test. This helps in aligning the test with medical necessity.
• Patient Demographics Matter: Fill out the patient's personal information accurately, including their preferred language and contact details. This facilitates effective communication.
• Insurance Details are Crucial: Attach copies of insurance cards and accurately fill in the insurance information. Ensure the “Policyholder Name” and “DOB” are completed if insurance details are submitted.
• Understand Payment Responsibilities: The patient must acknowledge their responsibility for any amounts not covered by insurance. This includes costs for non-covered services.
• Maintain HIPAA Compliance: Patients must consent to Authorizations and Assignments of Benefits. This ensures protection of personal health information while allowing billing processes to proceed smoothly.