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Forms

 

Requisition Forms

Oncology Test Requisition
English Informed Consent
Arabic Informed Consent
French Informed Consent
Spanish Informed Consent
Oncology Test Requisition (for Non-US Clients)
Add On Form

Family History Form

Please download our Family History Questionnaire to assist in determining if the patient’s personal or family history is suggestive of a hereditary cancer syndrome and if they are a candidate for genetics follow-up.

Family History Questionnaire

Family History Questionnaire Spanish

Commercial Insurance Forms

Aetna 

The Aetna Prior Authorization form must be filled out and signed by the order physician and sent along with the requisition. This form is only required for tests that include the BRCA1 and/or BRCA2 genes; see below:

B361 BRCA1/2 Ashkenazi Founder Mutation Panel
B362 BRCA1/2 Sequencing and Deletion/Duplication 
B502 BRCA1/2 Sequencing
B501 BRCA1/2 Deletion/Duplication (Only if Aetna Medicare)
B275 Comprehensive Cancer Panel 
B751 High/Moderate Risk Panel
B521 Breast Cancer High Risk Panel
B273 Breast/Ovarian Cancer Panel
B343 Pancreatic Cancer Panel
B344 Endometrial Cancer Panel
B749 OncoGeneDx Custom Panel (Only when BRCA1 or BRCA2 are selected)
B370-8 Testing for a previously identified familial mutation or variant (Only when BRCA1 or BRCA2 are ordered)

 
Aetna Prior Authorization Form 


Cigna
 

Cigna requires their cigna genetic counseling recommendation form be filled out for genetic testing.  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org or you can get a referral from InformedDNA.

Cigna Genetic Counseling Recommendation Form
InformedDNA Form GC Referral Form

 

UHC (United Healthcare)

Starting January 1, 2016 UHC will require a prior authorization form for BRCA testing to be filled out for genetic testing.  This form has to be completely filled out by the following:

  • Genetic Counselor
  • Advanced Genetics Nurse
  • Genetic Clinical Nurse
  • Advanced Practice Nurse in Genetics
  • A board-eligible or board-certified clinical geneticist
  • A physician with experience in cancer genetics (defined as providing cancer risk assessment on a regular basis and having received specialized ongoing training in cancer genetics. Educational seminars offered by commercial laboratories about how to perform genetic testing are not considered adequate training for cancer risk assessment and genetic counseling).

To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org or you can get a referral from InformedDNA.

UHC BRCA Prior Authorization Form
InformedDNA Form GC Referral Form

Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent. 

Medicare Criteria Form
ABN Form
Spanish ABN Form

Letters of Medical Necessity

BRCA1/2 Ashkenazi Founder Mutation Panel
BRCA1/2 Sequencing and Deletion/Duplication 
Comprehensive Cancer Panel 
Breast Cancer High Risk Panel
Breast/Ovarian Cancer Panel
Lynch/Colorectal High Risk Panel
Colorectal Cancer Panel
Pancreatic Cancer Panel
Endometrial Cancer Panel

 

 

Requisition Forms

Cardiology Test Requisition
English Informed Consent
Arabic Informed Consent
French Informed Consent
Spanish Informed Consent
Add On Form

Family History Form

Please download our Family History Questionnaire to assist in determining if the patient’s personal or family history is suggestive of a hereditary cardiac disorder and if they are a candidate for genetics follow-up.

Family History Questionnaire

Commercial Insurance Forms

Cigna 

Cigna requires their Cigna genetic counseling recommendation form be filled out for Long QT Syndrome (LQTS) genetic testing.  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. This form is only required for tests that include the LQTS genes; see below. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org or you can get a referral from InformedDNA.

484 LQTS Del/Dup Panel
727 LQTS Sequencing & Del/Dup Panel
360 LQTS Sequencing Panel
935 Combined Cardiac Panel
695 Comprehensive Arrhythmia Panel

Cigna Genetic Counseling Recommendation Form
InformedDNA Form GC Referral Form

Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent.

ABN Form
Spanish ABN Form

Letters of Medical Necessity

Hypertrophic Cardiomyopathy (HCM)
Dilated Cardiomyopathy (DCM) 
Long QT Syndrome (LQTS)
Short QT Syndrome (SQTS)

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Brugada Syndrome (BrS) 
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Marfan Syndrome/TAAD

 

Requisition Forms

Neurology/Mitochondrial Disorders Test Requisition
English Informed Consent
Arabic Informed Consent
French Informed Consent
Spanish Informed Consent
Xpanded Family Member Requisition
Add On Form

Commercial Insurance Forms

Cigna 

Cigna requires their cigna genetic counseling recommendation form be filled out for genetic testing.  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org.

Cigna Genetic Counseling Recommendation Form

Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent.

ABN Form
Spanish ABN Form

Letters of Medical Necessity

Comprehensive Epilepsy Panel
STAT Epilepsy Panel

Infantile Epilepsy Panel
Childhood-Onset Epilepsy Panel
Progressive Myoclonic Epilepsy Panel
Rett/Angelman Syndrome Panel
Tuberous Sclerosis Panel
Mitochondrial Testing

Requisition Forms

XomeDxXpress Test Requisition
English Exome Informed Consent
Arabic Exome Informed Consent
French Exome Informed Consent
Spanish Exome Informed Consent
XomeDx Test Requisition
XomeDx Family Member Req
English Exome Informed Consent
Arabic Exome Informed Consent
French Exome Informed Consent
Spanish Exome Informed Consent
XomeDxSlice Test Requisition
English Informed Consent
Arabic Informed Consent
French Informed Consent
Spanish Informed Consent
Add On Form

Consent for Release of Data

GeneDx Consent for Release of Data 

Commercial Insurance 

Prior Authorization 

Majority of insurance companies require prior authorization for genetic testing.  If prior authorization is required, a customer service representative will reach out to inform you and obtain any additional forms needed. 

Pre-authorization Template 

Cigna 

Cigna requires their cigna genetic counseling recommendation form be filled out for genetic testing.  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org.

WES Cigna Genetic Counseling Recommendation Form

Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent.

ABN Form
Spanish ABN Form

Letters of Medical Necessity

XomeDx
XomeDxPlus
 

Requisition Forms

Rare Disorders Requisition 
(All single gene and targeted tests) 
English Informed Consent
Arabic Informed Consent

French Informed Consent
Spanish Informed Consent
Prenatal Test Requisition
English Informed Consent
Arabic Informed Consent

French Informed Consent
Spanish Informed Consent
Cytogenetics Test Requisition
English Informed Consent
Arabic Informed Consent

French Informed Consent
Spanish Informed Consent
Add On Form 

 

Commercial Insurance Forms

Cigna 

Cigna requires their cigna genetic counseling recommendation form be filled out for genetic testing.  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org.

Cigna Genetic Counseling Recommendation Form

Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent.

ABN Form
Spanish ABN Form

 

 

 

 

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