Thank you for your interest in our Courtagen Care Financial Assistance Plan. Please provide all information requested below. Courtagen Diagnostics Laboratory cannot process an incomplete application.
All information provided in this application will be used only for the purpose of determining whether you qualify for the Courtagen Care Plan.
Courtagen agrees not to disclose any individually identifiable information provided in this application to any third party, except as provided herein or as required by law.

Please note that Courtagen does not accept Medicare or Medicaid. The Courtagen Care Plan is available only to those patients with commercial insurance.

All fields with asterisks are required. When Complete, click "Submit" on the bottom of this form.

Email Questions to Support@courtagen.com

Applicant Information

Required FieldCity 
Required FieldState 

Patient Information

Required FieldPatient Id Number  Patient ID number (in the email you received from Courtagen)

Income

Number of members in your household 
Required FieldAdjusted Gross Income  Adjusted Gross Income (AGI) from the most recent Federal Tax Return - this can be found on line 4 of IRS Form 1040EZ, line 21 of IRS Form 1040A, or line 37 of IRS Form 1040.

Expenses

Medical Expenses  Medical expenses, incurred in the previous calendar year, not including insurance premium payments that have been itemized on Schedule A, Line 1 of IRS Form 1040 (“Allowed Medical Expenses”)

Additional Information

Patient Declaration

Required FieldE-Signature  By clicking the e-signature box, I am agreeing to the disclaimer below. Click the "Submit" Button at the bottom of this form when complete.

I understand and consent that all of the information I am providing as part of this application will be used by Courtagen to determine whether I qualify for the Courtagen Care Financial Assistance Plan. I verify that the information on this application is complete, true, and accurate.

I understand that, if any of the information I have provided proves to be untrue, Courtagen may re-evaluate my financial status and take action necessary to collect an amount equal to the discount or waiver granted to me by Courtagen.

I also understand that there are terms and conditions to remaining in the Courtagen Care Plan, if approved. I hereby agree to:
  • Forward directly and timely to Courtagen any insurance plan payment for Courtagen genetic testing that is sent directly to me from my plan
  • Assist Courtagen in the claims process by supplying the relevant information necessary to issue a claim on my behalf
  • Assist Courtagen in an appeals process, if applicable, by supplying the relevant information or signatures of consent necessary to make claim appeals on my behalf
  • Assist Courtagen with any other reasonable request with the intent to maximize my insurance plan payment coverage.

If I do not comply with these conditions I understand that my Courtagen Care Plan can be nullified and I would then owe the remaining balance of the insurance claim. Under certain circumstances outstanding patient balances will be referred to an outside collections agency.