The FM1 Test
New Patient Form
Email address
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First Name
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Last Name
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Phone Number
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Please let us know about your insurance.
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Medicare
PPO
HMO/EPO
Do Not Have Insurance
You have HMO coverage.
HMO’s do not allow for outside laboratory testing, which is how the FM1 Test is accomplished. The FM1 Test is designated by the FDA as a Laboratory Developed TEST(LDT) which requires that the test be performed by the laboratory where it was developed. Therefore, you have 3 options: (1) Pay for the test yourself(we offer a no interest payment plan) (2) Appeal to to your HMO that they cover the cost of the FM1 Test because no HMO offers a peer-reviewed and confirmed accurate and objective blood test for diagnosing Fibromyalgia. If you have any questions please call us at 424-238-5217.
Name of Insurance
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Policy #
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Phone Number Of Insurer
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Format: (000) 000-0000.
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Do you have a Secondary Insurer?
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Name of your secondary insurance
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Policy #
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Phone Number Of Insurer
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Date of Birth
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Gender
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Address
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Please check any symptoms you have
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Pain & Tenderness
Sensitivity
Stiffness
Fatigue
Poor Sleep
Brain Fog
Lack of Energy
Headaches
Abdominal Problems
Irritable Bowel Syndrome (IBS)
Respiratory Problems
Restless legs
Depression
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Doctor's Name
Has your doctor already authorized the Blood Test?
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Yes
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I agree to receive communication from Precision Laboratories
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