1. Indicate sample type

2. Record the diagnosis codes for the panel from the available list, or supply your own in the 'Other ICD-9 Code' spac. Then select the whole profile or select test markers from the individual listings

This section is a customized printout identifying individual test components for each profile. For Genova Diagnostics to file for Medicare or Insurance compensation, you must specify a diagnosis code.

3. Record final collection date

Date Final Sample Collected box must be filled in for prompt processing. The physician or patient will fill this in depending on the sample collection type.

4. Have patients fill out and sign Patient Info section

To accession a patient in our laboratory computer system, the patient's name, date of birth, and gender must be clearly legible on the form.

5. Read the PayAssured™ Guidelines

Patients with Medicare, Medicaid, CHAMPUS, or Tricare coverage should carefully read the PayAssured™ Guidelines as they are not eligible for the PayAssured™ insurance billing program. If patient chooses to use the PayAssured™ program they must sign at the bottom of the guidelines.

6. Choose the billing method

Place a checkmark in one of the four boxes to select method of payment for the test. The patient's test cannot be processed until this section is completed. IMPORTANT: If you choose PayAssured™ or Medicare for the billing option you are required to specify individual test markers and diagnosis codes for each test you order (see Step 2).

7. Genova Diagnostics claims filing

Patients fill out this section ONLY if they want Genova Diagnostics to file a claim on their behalf.

8. Optional: Prepay

Available only if payment for testing is enclosed, physician or patient must provide check or credit card information.

9. Sign the Requisition

Also: Medicare coverage depends on physician's type of medical practice. BCBS patients can prepay OR file a claim, but NOT both. Medicaid coverage depends on patient's state of residence. Please update physician information if necessary.

Congratulations! Knowing how to complete the form properly will save you valuable time. If you have any further billing questions, please use our secure web contact center, or call our business office at 888-201-8333.