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Patient Information
Fill the patient information as accurately as possible and click the button to create an insurance letter
Patient Name (Optional)
Insurance Company Name
*
Doctor Name
*
Hospital Name
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Patient Indication
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Stage of Cancer
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Select stage
ECOG Status
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Select status
Number of previous lines of treatment
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Has biomarker testing been done?
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Yes
No
What will be the next step if you are not able to do the Optim.AI™ test?
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Select next step
Reason to request the Optim.AI™ examination
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Possible to select multiple answers
Guidelines have been exhausted for this patient.
The patient has aggressive / rapidly progressing cancer.
The patient’s health status does not allow for trial and error in the next treatment line.
The patient has a rare or complex cancer type with limited standard protocols.
The patient lacks traditional biomarkers to target.
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