• Submit a case Digitally

    DocuSign Submission & Payment (Recommended)

    Estimated time to complete: ~3 minutes

    Use this option for the fastest and most streamlined submission. This process includes electronic form completion, signature, and payment in one workflow.

    Step 1 - Access the Digital Form

    Click the link below to open the Case Management Request Form in DocuSign:

    (opens in a separate window for ease of referencing instructions)

    Step 2 - Enter Signatory Information

    You will first be prompted to enter your name and email address. This information identifies the signatory for Case Management authorization within DocuSign. (This step occurs before the form itself is displayed.)

    Step 3 - Complete and Sign the Form

    Once both the completed form and payment are received, BioConnetiX will initiate case coordination in accordance with the authorized scope and provide updates as services are coordinated.

    Step 4 – Submit Payment

    After submitting the form, you will be directed to remit the $250 Case Initiation Fee, payable by credit card, debit card, or ACH.

    Step 5 - We'll Take It From Here

    Once both the completed form and payment are received, BioConnetiX will initiate case coordination in accordance with the authorized scope and provide updates as services are coordinated. A copy of the fully executed form and payment confirmation will be emailed to you automatically for your records.

    Need a form?

    Download a PDF version here
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