Carrier Screening Test

Family History

Please attach detailed medical records and clinical information to the testing form.
Medical History

Cancelof
Family Member 1, First Name
Family Member 1, Last Name
Relation to Patient
Genetic Sex

MaleFemale
Diagnosis and / or Symptoms
Age of Onset
Date of Birth

MonthDayYear
Family Member 2, First Name
Family Member 2, Last Name
Relation to Patient
Genetic Sex

MaleFemale
Diagnosis and / or Symptoms
Age of Onset
Date of Birth

MonthDayYear
Family Member 3, First Name
Family Member 3, Last Name
Relation to Patient
Genetic Sex

MaleFemale
Diagnosis and / or Symptoms
Age of Onset
Date of Birth

MonthDayYear

Select a Test

Select your test(s) below. Pricing is $150 (one test); $275 (two tests) and $375 (three tests). You can also visit our about page for more information on each test.
Fragile X Dx [CPT: 81243]SMN [CPT 81329]CFTR [CPT: 81220]
Include Cheek Swab Collection Kit
A Collection Kit package costs $40 and includes 2 sample collection kits. Price includes domestic shipping costs and return packaging. Upon selection the kit will be mailed to you.
[HIDDEN] Number of tests selected
[HIDDEN] Collection kit add-to-cart value
[HIDDEN] Test price
[HIDDEN] E-Prescribed add-to-cart value
[HIDDEN] Price
Price
$20 fee has been added for MVL Prescription Service (Selected under "Applicant > Referral Information")
Please select a different payment method, or provide doctor's prescription.

A doctor's prescription is required when selecting "Insurance" as a payment method. Our MVL Prescription Service option (which you have selected above) does not qualify you for insurance as a payment method.

Payment
Payment method*

Self Pay - Credit, Debit, HSA CardInstitutional Billing
Insurance Billing

Attach front and back of all insurance cards, ABN, medical criteria form.

By signing below, the patient or insured authorizes MVL to release medical information concerning the test to the assigned insurance company.
Insurance requirements

A doctor's prescription is required when selecting Insurance as a payment method. Our MVL Prescription Service does not qualify you for insurance as a payment method.

Please take a photo (or upload) the front and back of your insurance card, as well as your photo ID. You can also provide this information at the time of specimen collection.
Photo ID
Insurance card (front)*
Insurance card (back)*
ICD-10 Valid Code*
First Name of Insured*
Last Name of Insured*
Relation to Patient*
Date of Birth*

MonthDayYear
Insurance card (front)*
Insurance card (back)*
First Name of Insured*
Last Name of Insured*
Relation to Patient*
Date of Birth*

MonthDayYear
If I am covered by insurance, I authorize MVL and their contracted billing company to give my insurance carrier the information on this form and provided by my healthcare provider that is necessary for reimbursement. I understand that I am responsible for deductible
and coinsurance amounts as indicated by my insurance carrier. I agree to assist in resolving insurance claim issue ans if I do not assist, I may be responsible for the cost of the test. I understand that I am responsible for sending MVL any and all of the money that I receive directly from my insurance carrier in payment for this test.

If the test is not authorized by or is not covered by my insurance, than I will be contacted with the option to either cancel the ordered test or elect to pay out-of pocket according to the proposed payment plan provided to me when I am contacted. If I elect to pay out-of-pocket, I will be responsible for all payment obligations arising from the ordered testing and guarantee payment for these services. I understand that if payments or arrangements are not made after 3 statements my information may be sent to collections.

MVL is committed to support you with your share of costs. If required, you will be contacted by our team to setup a payment plan for your portion of the costs using the following forms of payment: Check, Visa, Master Card. You may also contact our office at 503-227-3179.
Patient Signature (Required)*

Clear
Self Pay

By filling out the information below, the patient or payor authorizes Molecular Vision Lab to contact them directly, and use the provided billing instructions to bill the indicated method.

No charges will be posted until we receive your sample. Your card information will be handled using Stripe's secure online payment station. No card information is kept with the lab.
Use primary patient for billing information
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Email*
example@example.com
Billing Phone*
Please enter a valid phone number.

[HIDDEN] Stripe amount
Institutional Billing
Institution / Practice Name*
Attention to*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone*
Please enter a valid phone number.
Fax / Email*
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Carrier Screening Test

Applicant

Primary Patient

Referral Information

Order Provider

Family History

Select a Test

Please select a different payment method, or provide doctor's prescription.

Payment

Insurance Billing

Insurance requirements

Self Pay

Institutional Billing