Cancer Clear | Cancer Clear Test Order Form

Cancer Clear Test Order Form

All fields with (*) are required. Please call 855-DT-CANCER or 855-382-2623 for assistance filling out the Order Form.

Patient ID/MRN *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Sex (Male/ Female) *

Phone Number *

Language Preference

Email Address *

Your Shipping Address *

City, State, Zip Code *

Your Billing Address *

City, State, Zip Code *

Insurance Type (Insurance/ Medicare/ Medicare Advantage/ Medicaid/ Tricare/ Self-Pay) *

Policyholder Name *

Policyholder Date of Birth (mm/dd/yyyy) *

Relationship to patient: (Self/ Spouse/ Other) *

Insurance Carrier/Program *

Customer Service # on Insurance Card *

Claims Submission Address *

Subscriber ID/Policy Number *

Group Number *

Plan *

Healthcare Organization

Provider Name

NPI #:

Provider Location Address

City, State, Zip Code

Provider Phone Number

Provider Secured Fax Number

Test Name:

Test Description:

ICD-10 Code:

ICD Code Other(s):

CPT Code:

CPT Code Other: