WINTER 2020
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CGx Cancer Test program. EKRA Law Compliant!
- WE HAVE NOVITAS LABS AROUND THE COUNTRY TAKING PERSONAL AND FAMILY HISTORY
- Our Sales Program is perfect for Medical Sales Reps, Call Centers, Insurance Agents and more
- The ability to market to Physician's offices and others.
- Insurance plans include Medicare, BCBS, Aetna, Cigna, United, Humana, and other national programs etc., etc.
- Covered by 75% of insurance plans if immediate family member(S) had/has cancer.
- Aggressive EKRA COMPLIANT commission programs with regular cycle payouts.
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Hereditary Cancer Screening - Qualifying Patient Questionnaire
Please read and answer the questions below. While answering, consider relatives who are living along with those who have passed away, those who are sick and those in remission, male and female relatives, and relatives on both your mother and father’s side of the family.
“Relatives” refer to blood relatives and include: mother, father, son daughter, brother, sister, half-brother, half-sister, uncle, aunt, nephew, niece, grandparent, grandchild, cousin.
1. Have YOU ever been diagnosed with any of these cancers prior to the age listed?
[ ] BREAST CANCER (age 45 or younger) [ ] COLON CANCER (age 50 or younger) [ ] ENDOMETRIAL/UTERINE CANCER (age 50 or younger)
[ ] OVARIAN CANCER (any age)
2. Have YOU ever been diagnosed with either PROSTATE or PANCREATIC cancer? [ ] YES [ ] NO
IF YES: Do you also have ONE or more relatives diagnosed with any of these cancers?
[ ] PROSTATE CANCE R [ ] PANCREATIC CANCER [ ] BREAST CANCER (age 50 or younger)
3. Have YOU ever been diagnosed with BREAST cancer between ages 46-5 0 ? [ ] YES [ ] NO
IF YES: Do you also have any of the following?
[ ] ONE or more relatives diagnosed with BREAST CANCER, PANCREATIC CANCER or PROSTATE CANCER (at ANY AGE)
[ ] TWO or more relatives on the same side of the family diagnosed with BREAST CANCER at ANY AGE?
4. Have YOU been diagnosed with BREAST cancer at any age ? [ ] YES [ ] NO
IF YES: Do you also have any of the following? [ ] ONE or more relatives diagnosed with BREAST CANCER at age 50 or under?
[ ] TWO or more relatives on the same side of the family diagnosed with BREAST CANCER at ANY AGE?
5. Have any relatives been diagnosed with BREAST (age 45 and under) or OVARIAN cancer (any age ) ? [ ] YES [ ] NO
6. Do you have ONE relative that was diagnosed with BREAST cancer (any age ) ? [ ] YES [ ] NO
IF YES: Do you also have any of the following on the same side of the family? [ ] ONE or more additional relatives diagnosed with BREAST CANCER at age 50 or younger [ ] TWO or more relatives diagnosed with BREAST CANCER at ANY AGE?
7. Do you have ONE relative that was diagnosed with PANCREATIC OR PROSTATE cancer? [ ] YES [ ] NO
IF YES: Do you also have ONE or more additional relatives on the same side of your family diagnosed with any of these cancers?
[ ] PROSTATE CANCER [ ] PANCREATIC CANCER [ ] BREAST CANCER (age 50 or younger)
8. Do you have ONE Relative that was diagnosed with COLORECTAL or ENDOMETRIAL cancer? [ ] YES [ ] NO
IF YES: [ ] D o you also have ONE or more additional relatives on the same side of your family diagnosed at age 50 or younger with
any of these cancers: COLORECTAL or ENDOMETRIAL
[ ] Do you also have TWO or more additional relatives on the same side of your family diagnosed with any of these Cancers
at any age? COLORECTAL, ENDOMETRIAL, PANCREATIC, SMALL BOWEL, HEPATOBILIARY TRACT, LIVER, URINARY TRACT, RENA L
PELVIS, URETER, OVARIAN, BRAIN or STOMACH
Answering these questions does not guarantee that your insurance will cover a cancer screening. The screening is a predictive test that can identify if
you are at increased risk for certain types of cancer. It does not diagnose cancer or determine definitively if you will develop cancer in your lifetime.
Please read and answer the questions below. While answering, consider relatives who are living along with those who have passed away, those who are sick and those in remission, male and female relatives, and relatives on both your mother and father’s side of the family.
“Relatives” refer to blood relatives and include: mother, father, son daughter, brother, sister, half-brother, half-sister, uncle, aunt, nephew, niece, grandparent, grandchild, cousin.
1. Have YOU ever been diagnosed with any of these cancers prior to the age listed?
[ ] BREAST CANCER (age 45 or younger) [ ] COLON CANCER (age 50 or younger) [ ] ENDOMETRIAL/UTERINE CANCER (age 50 or younger)
[ ] OVARIAN CANCER (any age)
2. Have YOU ever been diagnosed with either PROSTATE or PANCREATIC cancer? [ ] YES [ ] NO
IF YES: Do you also have ONE or more relatives diagnosed with any of these cancers?
[ ] PROSTATE CANCE R [ ] PANCREATIC CANCER [ ] BREAST CANCER (age 50 or younger)
3. Have YOU ever been diagnosed with BREAST cancer between ages 46-5 0 ? [ ] YES [ ] NO
IF YES: Do you also have any of the following?
[ ] ONE or more relatives diagnosed with BREAST CANCER, PANCREATIC CANCER or PROSTATE CANCER (at ANY AGE)
[ ] TWO or more relatives on the same side of the family diagnosed with BREAST CANCER at ANY AGE?
4. Have YOU been diagnosed with BREAST cancer at any age ? [ ] YES [ ] NO
IF YES: Do you also have any of the following? [ ] ONE or more relatives diagnosed with BREAST CANCER at age 50 or under?
[ ] TWO or more relatives on the same side of the family diagnosed with BREAST CANCER at ANY AGE?
5. Have any relatives been diagnosed with BREAST (age 45 and under) or OVARIAN cancer (any age ) ? [ ] YES [ ] NO
6. Do you have ONE relative that was diagnosed with BREAST cancer (any age ) ? [ ] YES [ ] NO
IF YES: Do you also have any of the following on the same side of the family? [ ] ONE or more additional relatives diagnosed with BREAST CANCER at age 50 or younger [ ] TWO or more relatives diagnosed with BREAST CANCER at ANY AGE?
7. Do you have ONE relative that was diagnosed with PANCREATIC OR PROSTATE cancer? [ ] YES [ ] NO
IF YES: Do you also have ONE or more additional relatives on the same side of your family diagnosed with any of these cancers?
[ ] PROSTATE CANCER [ ] PANCREATIC CANCER [ ] BREAST CANCER (age 50 or younger)
8. Do you have ONE Relative that was diagnosed with COLORECTAL or ENDOMETRIAL cancer? [ ] YES [ ] NO
IF YES: [ ] D o you also have ONE or more additional relatives on the same side of your family diagnosed at age 50 or younger with
any of these cancers: COLORECTAL or ENDOMETRIAL
[ ] Do you also have TWO or more additional relatives on the same side of your family diagnosed with any of these Cancers
at any age? COLORECTAL, ENDOMETRIAL, PANCREATIC, SMALL BOWEL, HEPATOBILIARY TRACT, LIVER, URINARY TRACT, RENA L
PELVIS, URETER, OVARIAN, BRAIN or STOMACH
Answering these questions does not guarantee that your insurance will cover a cancer screening. The screening is a predictive test that can identify if
you are at increased risk for certain types of cancer. It does not diagnose cancer or determine definitively if you will develop cancer in your lifetime.