[email protected] | 855.698.

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NPI # 1184045619 | CLIA # 05D2070300 | CAP Accredited # 8765297
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Guardant Reveal™ Test Requisition & Statement of Medical Necessity
FOR COLORECTAL CANCERS ONLY. DOES NOT PROVIDE COMPREHENSIVE GENOMIC PROFILING RESULTS.
1. PATIENT INFORMATION REQUIRED 5. ORDERING PHYSICIAN (or other Licensed Medical Professional)
Last Name First Name Last Name First Name

DOB (mm/dd/yyyy) Sex Medical Record Number Email

F M
Street Address

City State Country Zip

Preferred Contact Phone Number Email (We will email status updates of your test)

New Guardant Health Patient Existing Guardant Health Patient

2. SPECIMEN INFORMATION REQUIRED

Collection Date (mm/dd/yyyy) Name of Person Collecting Specimen

Medical Professional Consent

3. STAGE REQUIRED Cancer types other than COLORECTAL are not currently accepted.
My signature constitutes a Certification of Medical Necessity, and I hereby authorize and
Stage ll Colorectal Cancer Stage lll Colorectal Cancer order Guardant Health, Inc. (GH) to perform Guardant Health testing for this patient as
indicated on this requisition, I have reviewed the medical consent on the back of this
4.RELEVANT DATES form and will provide test interpretation to the patient as appropriate. (continued on back)

Date of Original Diagnosis (mm/dd/yyyy) Medical Professional Signature Date

Completion of adjuvant chemotherapy (if applicable) (mm/dd/yyyy)

X
6. ADDITIONAL RECIPIENT
Medical Professional Name Phone Number Fax Number

7. ICD-10 CODE (CHECK ONE) REQUIRED

C18.0 Malignant neoplasm of cecum C18.6 Malignant neoplasm of descending colon C21.0 Malignant neoplasm of the anus, unspecified
C18.1 Malignant neoplasm of apendix C18.7 Malignant neoplasm of sigmoid colon C21.1 Malignant neoplasm of anal canal
C18.2 Malignant neoplasm of ascending colon C18.8 Malignant neoplasm of overlapping sites of colon C21.2 Malignant neoplasm of cloacogenic zone
C18.3 Malignant neoplasm of hepatic flexure C18.9 Malignant neoplasm of colon, unspecified refers to an anal cancer location.
C18.4 Malignant neoplasm of transverse colon C19 Malignant neoplasm of rectosigmoid junction C21.8 Malignant neoplasm of overlapping sites
C18.5 Malignant neoplasm of splenic flexure C20 Malignant neoplasm of rectum of rectum, anus and anal canal
Additional ICD-10 CODE(S)

8. GUARDANT REVEAL™ ORDERING (CHECK ONE OFFERING & YOUR PREFERENCE FOR MANAGING BLOOD DRAWS) REQUIRED
Post-surgery Program OR Surveillance Program (Up to 5 years after surgery) OR One Time Order
Time point 1: 4-6 weeks after surgery Every three months: 0-2 years after surgery
Time point 2: 9-11 weeks after surgery Every six months: 2-5 years after surgery
Time point 3: 16-18 weeks after surgery
9. PREFERENCE FOR MANAGING BLOOD DRAWS REQUIRED Mobile Phlebotomy In clinic

10. RELEVANT CLINICAL HISTORY REQUIRED

Date of Surgical Resection (mm/dd/yyyy)
Please see the back page
No Yes of this form for details
1. Is the patient currently on chemotherapy or targeted therapy for colon or rectal cancer?
reguarding Medicare
2. Does the patient currently have clinical, radiographic, or biologic evidence of recurrence or progression? No Yes coverage criteria.
3. Has the patient had molecular MRD surveillance or monitoring tests other than Guardant? No Yes

11. BILLING INFORMATION Please attach a copy of the front and back of the patient’s insurance card and/or the patient face sheet
Patient Status (Medicare only) Hospital Inpatient Hospital Outpatient Non-hospital Patient

Insurance (please fill in below) Medicare - Part B Medicaid Hospital/Institution Self-Pay (Please contact Client Services for billing information)
Primary Insurance Insured Name Policy # Group #

Patient Relationship Insured DOB

to Insured Self Spouse Child Other

FRM-PRT-000054 R3

| 505 Penobscot Drive | Redwood City, CA 94063 | T 855.698.8887 | F 888.974.4258 FRM-PRT-000054 R3

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 [email protected] | 855.698.8887
NPI # 1184045619 | CLIA # 05D2070300 | CAP Accredited # 8765297

Test Requisition & Statement of Medical Necessity continued

5. Medical Professional Consent (continued from front)
As may be required by applicable state laws and regulations, I have supplied information to the patient regarding Guardant Reveal, and the patient has given consent for this testing to be performed
by Guardant Health and for the results to be reported back to me in my management of this patient. I have obtained in writing the patient’s data privacy consent to transmit the health data on this
requisition form for the purpose of processing this order and performing Guardant Reveal. I understand that I remain free in my medical decisions on how to use the results of Guardant Reveal in my
management of this patient.
I hereby authorize GH to release test results and relevant medical information to the patient’s third-party payer when necessary as part of the reimbursement process. I have obtained the patient’s
consent for GH to submit claims and, if necessary, to appeal claims on the patient’s behalf to pursue reimbursement, as well as for GH to receive payment directly from the patient’s insurance carrier.
Medicare will only pay for tests that meet the Medicare coverage criteria and are reasonable and necessary to treat or diagnose an individual patient. With respect to tests reimbursed by Medicare,
Medicaid or other third-party payers, I attest that Guardant Reveal testing is medically necessary and the results will be used in the management of the patient’s condition. I agree to provide a copy
of relevant clinical history and medical records in order to support a request from a health plan, at no cost to Guardant Health. I acknowledge that patients who are United States residents may be
enrolled in Guardant Access, GH’s Financial Assistance Program only if they sign the assignment of benefits form.
If I have elected the adjuvant recurring ordering program on the front side of this form, I authorize Guardant Health to test for time point 1(T1), and reach out to the patient approximately 8 weeks
after the surgery date on the front of this form to schedule a second blood draw for time point 2 (T2), and again approximately 15 weeks after the surgery date to schedule a third blood draw for time
point 3 (T3).
If I have elected the surveillance recurring ordering program on the front side of this form, I authorize Guardant Health to test the initial sample. I further authorize Guardant Health to reach out to me
or my representative in advance of the recurrent three month or six month time points. Upon order confirmation I authorize Guardant Health to reach out to the patient to coordinate the blood draws.

For Medicare Beneficiaries Only

A Medicare Advance Beneficiary Notice (ABN) must be provided to a Medicare patient with colorectal cancer that does not have Stage II or Stage III disease or has not had surgical
resection. ABN forms that have been pre-populated with Guardant Health’s tests/prices can be obtained from Guardant Health Customer Service or inside the Guardant Reveal kit.
Completed ABN forms can be sent to Guardant Health with the kit/sample, via fax at 888.974.4258, or emailed to: [email protected]

Patient Assignment of Benefits Form (required)

ASSIGNMENT OF BENEFITS
I hereby assign and convey all applicable health insurance benefits and/or insurance reimbursement, as well as all rights and obligations that I have under my health plan, to
Guardant Health for services performed by Guardant Health. I appoint Guardant Health as my authorized representative to
- File medical claims with my health plan;
- File appeals and grievances with my health plan;
- File appeals or grievances with an external review committee at a state insurance board, independent review organization, Office of Personnel Management, Department of
Labor or equivalent agency;
- File a complaint, regarding inaccurate claims processing, appeal processing or pricing to CMS or their agent regarding my Medicare Part C plan
- Release medical and insurance information necessary to process claims or appeals;
- Obtain medical records related to services provided by Guardant Health when it is required to process a claim or appeal;
- Collect payment of any and all medical benefits and insurance proceeds directly from my health plan (including Medicare and Medicaid);
- Resolve any insurance related matter regarding a service provided by Guardant Health directly with my health plan
I acknowledge and agree that I remain responsible for applicable co-payments, deductibles and co-insurance as required by my medical and/or other healthcare benefits plans.
If I receive payment of medical and/or other health benefits on account of services provided by Guardant Health I shall pay Guardant Health the full amount of that payment.

AUTHORIZATION RELEASE
I hereby authorize Guardant Health to
- Release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments;
- Process and submit insurance claims generated in the course of examination or treatment; and
- Allow a photocopy of my signature to be used to process insurance claims, payment, grievances or appeals. This authorization will remain in effect until revoked by me in writing.

OUT-OF-NETWORK DISCLOSURE AND PATIENT CONSENT

I understand that Guardant Health services may be designated as an out-of-network service by some insurance plans. As a result, there may be costs associated with these
services that are not covered by my insurance plan. I hereby consent for out-of-network services to be provided by Guardant Health.
You may visit www.guardanthealth.com/insurance for a list of insurance plans that consider Guardant Health services as in-network. Guardant Health will provide upon request,
the estimated amount that Guardant Health expects to bill for services associated with out-of-network plans.
ERISA AUTHORIZATION
I hereby designate, authorize, and convey to Guardant Health, to the full extent permissible under law and under any applicable insurance policy and/or employee health care
benefit plan, the following:
- The right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action against my health plan that I may have under such
insurance policy and/or benefit plan; and
- The right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including,
but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R.
§2560.5031(b)(4)) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim
on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. I understand I can revoke this authorization in writing at any time.
ELIGIBILITY FOR FINANCIAL ASSISTANCE
I hereby consent Guardant Health to evaluate my eligibility for the Guardant Health Financial Assistance Program.
A photocopy of this Authorization shall be as effective and valid as the original.
This form is not an Advanced Beneficiary Notification (ABN).
If you have any questions, please do not hesitate to contact us at 1.855.698.8887 or [email protected].

PRINT NAME OF PATIENT DATE

SIGNATURE OF PATIENT EMAIL

| 505 Penobscot Drive | Redwood City, CA 94063 | T 855.698.8887 | F 888.974.4258 FRM-PRT-000054 R3

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