Please note this is NOT a Cologuard order form. The statement of medical necessity form should not be sent to Exact Sciences Laboratories.
By clicking this button, you are acknowledging that you have read and understand the following: This sample documentation demonstrates one or more ways Exact Sciences believes a healthcare provider may position Cologuard® with a third-party insurance payor when the healthcare provider has determined the medical necessity of the test and is seeking the insurance company’s authorization to confirm its coverage of the resulting charges. This sample documentation is essentially a compilation of information that has previously been made freely available in the public domain, and Exact Sciences provides it in this form to anyone who requests it, without regard to their ability or intention to order or recommend Exact Sciences’ device or services.
This sample documentation was created in July, 2015. Changes in applicable laws, rules, regulations, insurance company practices, codes, etc. may necessitate changes to the information contained in this documentation in connection with its use in practice. Exact Sciences makes no representations or warranties with respect to the accuracy or completeness of this information or any coverage decisions that may result from its use. Those who are considering using this documentation in any way should develop their own analyses and conclusions about the information and processes relevant to such authorization and coverage matters, including the potential inclusion of an independent advisor with expertise on such issues. Also, healthcare providers using this documentation are solely responsible for the accuracy of all information contained within it, including without limitation statements regarding a patient’s meeting the indications for Cologuard®.