HIPAA COMPLIANT - Enable Biosciences Test Requisition Form

1

Patient's Email* This field is required.If possible, please use the same email provided in the Test Order Form.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

2

Patient's Legal Name* This field is required.Please enter the Patient's full legal name. Avoid using shortened names or nicknames.

First Name

Last Name

3

Card CodeInput the alphanumeric code found on the bottom right corner of your blood spot card.

4

Patient's Home Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

5

Patient's Birth Date* This field is required.

Date

6

Patient's Phone Number

7

Does the Patient have a family history of type 1 diabetes?* This field is required.

Yes, the Patient has type 1 diabetes

Yes, a family member other than the Patient has type 1 diabetes

No

Other/Don't know/Prefer not to disclose

8

Who should be billed for the test?* This field is required.

Patient's Insurance

Clinic

The Patient (out-of-pocket)

Referral code

Other

9

Clinic Name* This field is required.

10

Referral Code* This field is required.Input the alphanumeric referral code you were provided.

11

Pay Out of Pocket* This field is required.

My Bag

1

Type 1 Diabetes Autoantibody TestType 1 Diabetes Autoantibody Panel
$169Edit
Back

Payment Methods

Credit Card

First Name

Last Name

Google Pay

After submitting the form, you will be redirected to the Google Pay to complete the payment process.

Apple Pay

After submitting the form, you will be redirected to the Apple Pay to complete the payment.

12

Insurance Company Name* This field is required.

13

Insurance Company Carrier CodeEnter the carrier code for your insurance provider. This code helps route claims correctly and can be found on your insurance card or by contacting your insurer.

14

Insurance Company Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

15

Insurance Company Phone Number* This field is required.

16

Upload a Photo of Insurance CardIf you don't have a photo available, select "Next" and the app will prompt you to take photos of the front and back of the insurance card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Take Photo of Insurance Card (Front)

18

Take Photo of Insurance Card (Back)

19

Subscriber's Name* This field is required.

20

Subscriber's Sex* This field is required.

21

Subscriber's Email Address* This field is required.

example@example.com

22

Subscriber's Phone Number* This field is required.

Area Code

Phone Number

23

Subscriber's Relationship to Patient* This field is required.

24

Subscriber's Date of Birth* This field is required.

Date

25

Subscriber's Member ID #* This field is required.

26

Subscriber's Group #* This field is required.