PGx America Corporation is a marketing company pairing great diagnostic laboratories with great medical practices across the nation.  We never touch specimens or patients but we do touch lives by introducing tomorrow's lifesaving technology to healthcare providers today.


This form is mandated by law to inform the patient of the medical rationale and the insurance responsibility.  It is boilerplate and confusing but no moreso that any other company's and it's required by law.  That is why we created the PGx Policy Form.  This form MUST be sent to lab with sample.


This plain language form is designed to handle three functions at once:  

First, it is important that patients and providers alike understand that PGx America labs will not refer patient responsibilities to collection agencies or the credit bureaus.  EOBs, bills, copays and deductibles are addressed here.  This is a relatively inexpensive test and no patient who needs it should be denied due to insurance.

Second, it explains in clear terms the medical necessity of the procedure, informing the patient before they meet with the doctor.  This results in educated questions and most patients will be excited to have the test done when they understand the benefits

Third, it is important that test results are shared with other prescribing doctors from other practices.  PGx America will take on the burden of notifying those providers and supplying them with results and pro bono consultations.  Although a practice may be able to bill for a follow-up consultation by phone or in person, this frees practice staff from non-compensated responsibilities.

This form is NOT to be sent to lab with sample but rather save them and fax to the number on the form once a week.

Quiz 4

 PGx University

‚ÄčLesson 4

Humans have 46 diploid chromosomes compared to 24 in rice, while a dog has 70 chromosomes. This proves all documents are not created equally.  Here are the simple documents a practice will encounter with PGx America. 


All practices need tofill out this online formwhich will give us the information needed to implement smoothly and effectively.  Reps may fill out this form but it is recommended that the managing physician do so.  

The process of filling out the form will give a practice manager/doctor an understanding of the responsibilities they are assuming.  We do not hold a practice to any contractual expenses or minimums or mandates but we do expect them to exert the necessary effort to be successful.  A practice that does not enter into PGx testing with energy will not serve their patients well and be a poor reflection of PGx America.

If a rep fills out the form and the practice is accepted as a PGx Clinic, implementation will begin immediately but a practice manager will need to initial a paper copy on Day One implementation to authorize HIPAA compliant communications.


This form comes with each swab kit and is addressed from the practice/prescribing physician to the lab.  It includes most of the common coding that will be required to properly submit the sample for testing and billing.  PGx America clinical staff will go over this form in depth so it is best that a staff have one person who can be the "expert". This form needs to go into the Fedex bag with each sample swab.