PASS Mgen Test Verification Form
Please submit your most recent Mycoplasma genitalium test or signed doctor's note indicating completion of treatment to post the verification of your Mgen clearance status on your app.passcertified.org account. Your submission is voluntary, though without it you will not be eligible for clearance in the PASS database after October 1, 2023. You will need to create a PASS account (app.passcertified.org) if you do not currently have one.

If you have any questions, please contact info@passcertified.org
Personal Information
Name (Legal)*

First NameLast Name
PASS ID*
The ID Number associated with your PASS account. If you do not have one, please create an account at app.passcertified.org
Email *
Email should match PASS account information.
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Mgen Testing or Treatment Information
Please upload a clear image of your government issued ID.*

Cancelof
Please upload a photo of your Mgen test or signed doctors note*

Cancelof
I, First Name* Last Name* , hereby declare that the information provided is true and accurate, and understand that it will be used to make health and safety decisions. I also understand that any willful dishonesty may render the refusal of this application or immediate termination my app.passcertified.org account, and I will accept any liability that may come from my misrepresentation of my provided information.
Signature*

Please sign your name in the field above. Clear
Should be Empty:

PASS Mgen Test Verification Form

Personal Information

Mgen Testing or Treatment Information

Performer Availability Screening Service, Inc.