Resources for Clinical Providers

We support clinicians, pharmacists and practices with the information they need to order tests and help their patients. 


What forms do your patients need when sending their tests back to GnomeDX? 

These forms are all provided in the GnomeDX kit. 


Self Pay

Requisition Form 

Non-Coverage Form



Requisition Form

Medical Necessity Letter

Non-coverage Form



Requisition Form

Medical Necessity Letter

Non-coverage Form



Sample reports

Request a sample report by contacting us.


Patient self-pay

GnomeDX's Cardiac, Mental Health, Polypharmacy and Pain Management test are offered at a self-pay price of $325. Online payment is required before the test can be processed. 

Insurance billing

Our pricing is simple. All tests require an upfront payment of $325. Although initial online payment is required before the test can be processed, GnomeDX can submit a claim to insurance or Medicare to be reimbursed. The forms required to submit to insurance are included in the GnomeDX kit and are labeled clearly. Once received, we will review the insurance information and GnomeDX will submit the claim. Prior authorization is the responsibility of the prescribing clinician’s office.

For the quickest response to payment questions please contact us at 614-431-6414 or email us at

Like any other lab test, insurance coverage and reimbursement policies vary by plan and provider. Patients should contact their insurance provider about their pharmacogenetic (PGx) testing policies. For convenience, below is a list of codes to check insurance eligibility. Each code corresponds to a gene in our panel. View the CPT Codes.