Clinic Forms

Credit Card Authorization

Authorization to use your credit card is necessary for fees and shipping/handling charges. Please fill out and submit the credit card authorization form to SCSA.



Physicians must provide written consent before the SCSA® test will be provided to any patient. SCSA® Diagnostics, Inc. will accept a standard requisition form from the attending physician or the Sperm Chromatin Structure Assay (SCSA®) Requisition Form below. The requisition may be returned in the shipment with the semen sample or directly faxed to SCSA® Diagnostics, Inc. (605-592-9021). Alternatively, a physician can authorize the SCSA test on a routine prescription form that is faxed (605-592-9021) or included in the return shipper. The authorization may be sent after the sample has been received and analyzed. Patients may also request an SCSA test on their own, but without insurance reimbursement.