Patient Information Form

Patient and billing information

Please fill out the form below, which allow us to bill your insurance correctly.

First name

Last name

Address

City

State

Zipcode

Phone

Date of birth

Sex

Race/ethnicity

Name of insurance plan

Policy number

Group number

Name of policy holder

Date of birth

Patient relation to policy holder

self spouse child

Specimen collection information

Check here if: “I do NOT consent to CirrusDx retaining the remnants (left over specimen) after the requested testing. The left-over specimens are typically used for Quality Control, assay improvement, or other purposes mainly to further improve testing by CirrusDx. My specimen is to be processed solely for the requested test.”

Patient Authorization

I understand that I am responsible for all co-pays and deductibles, and for amounts not covered by insurance, litigation or third-party liability. I am authorizing CirrusDx to submit claims and acknowledging that payment(s) of authorized insurance benefits or attorney settlements, including but not limited to Medicaid, Medicare, other benefits or payments shall be made on my behalf to CirrusDx. If my current policy prohibits direct payments to CirrusDx, I agree to receive the funds and relinquish them to CirrusDx as payment towards charges for services rendered.

Signature

Date