Please check if this is the first submission for your patient or a resubmission. If this submission is part of a study please indicate the study name/IRB Code.

Section I. Patient Information - to be filled out by a patient

Complete all lines. Some lines require more than one piece of information.

Section II. Billing Information - to be filled out by a healthcare professional
A. Complete the Submitting Diagnosis and associated ICD-9 Code fields.
B. Check whether the patient is a Medical patient or is using health insurance.
a. Include a copy of both the front and back of the patient's health insurance card (and if applicable the front and back of any secondary health insurance card(s)).
b. Write down the Medical number if applicable.

Ensure the patient has filled out all fields except the "referral/authorization#" if the patient has health insurance. Glycominds will contact the ordering physician if necessary for any "referral/authorization#".
If the patient has more than one health insurance policy, please note which is the primary one.

Section II. Billing Information - to be filled out by the patient
C. Please complete all the fields in the insurance section. You do not have to fill the "Referral/Authorization#" field.
Glycominds will contact your physician if this required by your health insurance plan. Please include the name of the person responsible for payment. This is typically the employee or the plan subscriber. Also include this person's date of birth, sex and relationship to the patient.

Section III. Patient Authorization - to be filled out by the patient
Please sign and date at the time of the office visit.

Section IV. Ordering Physician Information - to be filled out by a healthcare professional
A. Please complete all information.
B. Please select either the gMS^®Dx or gMS^®Pro EDSS from the Test Menu.
C. Sign and date the Test Requisition Form and Statement of Medical Necessity. Print your name. The signature must be that of the ordering physician, or their authorized representative. Your signature constitutes a Statement of Medical Necessity.

Section V. Specimen Collection Information
This section is to be filled out by the phlebotomist at the time of sample collection. If the sample is to be drawn on premises, have the patient take their copy of the completed Test Requisition Form and Statement of Medical Necessity with them to the phlebotomist.

How to Submit this form and receive test results
A. Complete all sections of the form. Missing information may result in delay in test results.
B. After both the ordering physician and patient sign this form, fax the completed form along with the front and back of the patient's insurance card(s) to 1-877-820-0961.
C. Test results will be available online at www.gms.net/testresults. A printed copy will be mailed to the ordering physician. Patient test results can be viewed online or downloaded as a PDF to your personal computer. A Lab Client Code and Password will be required to access the report online. Ordering Physicians will need to register with Glycominds at 1-800-643-4906 to obtain a Lab Client Code and Password.