If you have HMO or EPO insurance, you are often limited to the diagnostic tests your HMO/EPO network performs but you have the right to demand that your HMO or EPO pay for the FM/a ® Test as no HMO or EPO network is licensed to perform the FM/a ® Test and your HMO/EPO network has an obligation to provide medical tests that are at the current standard of medical practice and the only way to objectively diagnosis fibromyalgia via an FDA-compliant test is to have the FM/a ® test. If they still refuse, we can assist you in having the FM/a ® Test. We have a no-interest payment plan. That way you can pay for the FM/a ® test yourself. The cost of the test is $936 and via our our credit card payment option you simply tell us how many months you require (from 1-18 months) for payment. Please be sure to complete the remaining portions of this form.