MitoSwab - Test Requisition Form

5110 Campus Drive, Suite #120 | Plymouth Meeting, PA 19462

T: 484-534-9311 | F: 484-842-3400 | E: support@mitoswab.com | https://mitoswab.com
New SampleReplacement Sample
Date Specimen Collected

MonthDayYear
Date
Initial Here
SAMPLE INFORMATION [PROVIDER TO COMPLETE]
Specimen Type: MitoSwab™ Buccal Swab
FAXEmailOther
FACILITY INFORMATION [PROVIDER TO COMPLETE]
Physician Name:*

First NameLast Name
Facility Name*
Street*
City*
State*
Zip*
Country*
Telephone*
Format: (000) 000-0000.
Secure Fax
Email*
example@example.com
NPI
Physician acknowledgement: I hereby confirm that the information, including the information related to medical necessity as provided on this form, has been provided to the patient specified below and/or their legal guardian about the test(s) to be performed, and the patient specified below and/or their legal guardian has given consent for the test(s) to be performed. confirm that the person listed as the ordering physician who has signed below is authorized by law to order the test(s) requested herein.
Physician Signature*

Clear
Title*
Date*

MonthDayYear
Date
PATIENT INFORMATION [PROVIDER TO COMPLETE]
Patient Name:*

First NameLast Name
Date of Birth: (mm/dd/yyyy)*

MonthDayYear
Date
MaleFemale
Street Address:*
City:*
State/Region:*
Zip/Postal Code:*
Country*
Phone: *
Format: (000) 000-0000.
Email*
example@example.com
YesNo
PAYMENT INFORMATION: PHYSICIAN ACCOUNT BILLING
PATIENT CONSENT & AUTHORIZATIONS

Patient acknowledgment: My healthcare provider has provided me with information regarding the tests requested on this form. I agree that I am voluntarily submitting this sample for analysis. I authorize my physician to release the sample, and any other necessary records as requested to Religen Inc. and for Religen Inc. to release the results of MitoSwab TM to the ordering physician. I am aware that payment is required at the time of service and authorize Religen, Inc. to process the payment using the details above. I authorize Religen, Inc. and any third-party billing company contracted with Religen, Inc. to submit a claim for payment along with any required information for purposes of collecting payment from my insurance provider, if applicable. I understand if my insurance provider remits payment directly to me, I am to forward said payment directly to Religen, Inc. I understand that I am responsible for all charges not covered by my insurance provider, including any deductible, copayment or coinsurance as directed by my health insurance carrier(s)
Patient/Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Responsible Party, if other than Patient
Relationship to Patient
COMPLETE, SIGN, AND RETURN ALL DOCUMENTS WITH THE SAMPLE
CLIA ID #: 39D2130307
RI-MTS-0010 version 03

Effective Date: 04/01/2025
Should be Empty:

5110 Campus Drive, Suite #120 | Plymouth Meeting, PA 19462

SAMPLE INFORMATION [PROVIDER TO COMPLETE]

FACILITY INFORMATION [PROVIDER TO COMPLETE]

PATIENT INFORMATION [PROVIDER TO COMPLETE]

PAYMENT INFORMATION: PHYSICIAN ACCOUNT BILLING

COMPLETE, SIGN, AND RETURN ALL DOCUMENTS WITH THE SAMPLE