CORONAVIRUS DISEASE (COVID-19) VIRUS TESTING

CORONAVIRUS DISEASE (COVID-19) VIRUS TESTING
PRIMARY PATIENT
ORDERING PROVIDER
Name
INSTITUTION/PRACTICE NAMELAST NAME
FIRST NAME
INSTITUTION PHONE/FAX/EMAIL
example@example.com
DATE OF BIRTH (MM/DD/YYYY)
MonthDayYear
Date
GENETIC SEX
MaleFemaleUnknown
Name
PROVIDER FIRST NAMEPROVIDER LAST NAME
MED REC#/PATIENT IDENTIFIER
ETHNICITY
NPI (USA)
MINC (CANADA)
PROVIDER TITLE (MD, DO, GC)
ADDRESS
PROVIDER ADDRESS
CITY
STATE/PROVINCE
POSTAL CODE
COUNTRY
CITY
STATE/PROVINCE
POSTAL CODE
COUNTRY
PHONE
EMAIL
example@example.com
PROVIDER PHONE
FAX REPORT TO
SAMPLE TYPE
NASALOROPHARYNGEALNASOPHARYNGEALRNA
COLLECTION DATE (MM/DD/YYYY)
MonthDayYear
Date
GC/PRIMARY CONTACT
GC/PRIMARY CONTACT PHONE/EMAIL/FAX
example@example.com
I have read the Informed Consent document and I give permission to Fulgent Genetics to perform genetic testing as described. I also give permission for my specimen and clinical information to be used in de-identied studies at Fulgent and for publication, if appropriate. My name or other personal identifying information will not be used in or linked to the results of any studies and publications. More information is available at www.fulgentgenetics.com/policies/privacy-policy.
I attest that the patient has received and read the Fulgent Informed Consent document, or has had it read to him or her, and that I have fully informed the patient about the purpose, capabilities, and limitations of the ordered test. The patient has voluntarily given his or her full consent for the ordered test and a signed copy of this consent is available on le. Any Fulgent Informed Consent that the patient agrees to at a later date will supersede and replace this Informed Consent.
STATEMENT OF MEDICAL NECESSITY
By signing below, I, the ordering Medical Provider, conrm that testing is medically necessary and that test results may impact medical management for the patient.
Opt out of researchCheck this box if you are a New York state resident and give permission for Fulgent to retain any remaining sample longer than 60 days after the completion of testing.
TEST REQUESTED
TEST NAME
Coronavirus Disease (COVID-19) Virus Testing by Next Generation Sequencing (NGS)
ICD-10 CODES - Select/indicate ICD-10 code(s)
Pneumonia (COVID-19) J12.89 Pneumonia, Other viral pneumonia B97.29 Pneumonia, Other coronavirusR05 CoughR06.02 Shortness of BreathLower Respiratory Infection (COVID-19) J22: Acute lower respiratory infection, Unspecied B97.29 Pneumonia, Other coronavirusR50.9 Fever, UnspeciedJ01.90 Acute Sinusitis, UnspeciedAcute Bronchitis (COVID-19) J20.8 Acute Bronchitis, Unspecied B97.29 Pneumonia, Other coronavirusJ02.9 Acute Pharyngitis, UnspeciedJ06.9 Acute Upper Respiratory Infection, UnspeciedBronchitis (COVID-19) J40 Bronchitis, Unspecied B97.29 Pneumonia, Other coronavirusJ18.9 Pneumonia, Unspecied organismJ20.9 Acute Bronchitis, UnspeciedZ03.818 Suspected exposure to COVID-19J32.9 Chronic Sinusitis, UnspeciedZ20.828 Known Exposure to COVID-19Other:
ICD-10 CODES - Select/indicate ICD-10 code(s)
SAMPLE REQUIREMENTS & SHIPPING INSTRUCTIONS
- Minimum of 50 μl of RNA, with 80-100μl preferred.
- Store and ship specimens on dry ice overnight.
Nasal/Nasopharyngeal/Oropharyngeal Specimens:
- Store specimen in freezer/refrigerator prior to shipping
- Ship overnight on ice packs within 24hrs of collection (preferred method
c. Label each specimen with at least two unique identiers that match the TRF
(e.g. - patient rst and last name; DOB; MRN
d. Please insert all paperwork into the outside pocket of the specimen bag.
Send completed TRF with collected sample to:
Fulgent Genetics 4978 Santa Anita Ave. Temple City, CA 91780
INSURANCE BILLING
Attach front and back of all insurance cards, ABN, medical criteria form
PLEASE ATTACH INSURANCE CARDS FOR BILLING
ICD-10 VALID CODE
REFERRAL/PRIOR AUTH
FULGENT BENEFITS ID
By signing above, the patient or insured authorizes Fulgent Genetics to release medical information concerning the test to the assigned insurance company.
PRIMARY INSURANCE ID
INSURANCE NAME
S TAT E
GROUP
INSURANCE PHONE
INSURANCE PLAN
NAME OF INSURED
RELATION TO PATIENT
DATE OF BIRTH (MM/DD/YYYY)
MonthDayYear
Date
SECONDARY INSURANCE ID
INSURANCE NAME
S TAT E
GROUP
INSURANCE PHONE
INSURANCE PLAN
NAME OF INSURED
RELATION TO PATIENT
DATE OF BIRTH (MM/DD/YYYY)
MonthDayYear
Date
INSTITUTIONAL BILLING
SELF PAY
PRIMARY PATIENT
INSTITUTION/PRACTICE NAME
INSTITUTION/PRACTICE NAME
Use patient information above for billingUse information below for billing
By signing above, the patient or payor authorizes Fulgent Genetics to contact them directly, and use the provided billing instructions to bill the indicated method.
ATTENTION TO
Name
PAYOR FIRST NAMEPAYOR LAST NAME
ADDRESS
ADDRESS
CITY
STATE/PROVINCE
POSTAL CODE
COUNTRY
CITY
STATE/PROVINCE
POSTAL CODE
COUNTRY
PHONE
FAX/EMAIL
example@example.com
PHONE
FAX/EMAIL
example@example.com
4978 S anta A nita Ave., S uite 20 5, Temple Cit y, CA 9 1780 USA | www. FulgentG enetic s .com | info @fulgentgenetics.com | P + 1 626 . 3 50.05 37 | F +1 626 . 4 5 4 .16 67 2020 © Fulgent G enetics. A ll Rights Reser ved . | CLIA: 05D2043189 | NPI: 05D2043189 | D# TRF-COVID19-2020-V2
INSTITUTION PHONE/FAX/EMAIL
example@example.com
PATIENT SIGNATURE (REQUIRED FOR BILLING PURPOSES)
DATE (MM/DD/YYYY)
MonthDayYear
Date
ORDERING PROVIDER SIGNATURE (REQUIRED)
DATE (MM/DD/YYYY)
MonthDayYear
Date
Should be Empty:

CORONAVIRUS DISEASE (COVID-19) VIRUS TESTING

PRIMARY PATIENT

ORDERING PROVIDER

STATEMENT OF MEDICAL NECESSITY

TEST REQUESTED

TEST NAME

SAMPLE REQUIREMENTS & SHIPPING INSTRUCTIONS

INSURANCE BILLING

INSTITUTIONAL BILLING

SELF PAY

PRIMARY PATIENT