Patient Billing Estimate

If you have any questions regarding pricing and would like one of our representatives to provide you with an estimate for testing services, please complete the contact form below. Please note that the estimate is dependent on accurate patient information, and is subject to your specific plan benefits. This complimentary assessment is performed using currently available information and does not guarantee final billing amounts.

The NxGen MDx Team is Here to Assist You

Monday – Friday 8:30am – 7pm (EST)

Patient Name *

First

Last

Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Patient Date of Birth *

Insurance Name *

Group ID

Your Name *

I Am Interested In An Estimate For... *

Provider State

If available, please provide the diagnosis code(s) submitted with your test order.

Gender *

Member ID *

Relationship to Patient *

Your Date of Birth *

Provider Name

Upload Insurance Card

Click or drag files to this area to upload. You can upload up to 2 files.

Upload the front and back of your insurance card.

Additional Comments