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Required Forms

For any specific gene sequence analysis, known familial mutation test, or CopyDx quantitative analysis of a single gene...

1.   Use the 7-page requisition form called: Genetic Test Sample Submission Form

2.   Please use an Informed Consent Document to discuss the benefits, limitations, and risks associated with genetic testing. Consents should be signed by the individual being tested (or guardian), the individual who explained the testing, and by a witness. Suggested texts are provided:
  • DIAGNOSTIC SEQUENCING TESTS: Consent documents containing the sensitivity information for specific genes and diagnoses can be found by locating the Gene or Disease to be tested under Diagnostic Tests in the menu on the left.


  • OTHER TESTS OFFERED: All-purpose consent documents (for any gene) for CopyDx, Carrier tests, or Mutation Confirmation services can be found by clicking those sections of the menu on the left.
OR

For GenomeDx Oligo Array CGH...

1.   Use the 3-page requisition form called: GenomeDx Sample Submission Form

2.   Note that GenomeDx Oligo Array CGH testing has a mandatory statement of informed consent. It is attached as a third page to the above form.

OR

For AutismDx Autism Diagnostic Testing...

1. Use the 4-page requisition form called: AutismDx Sample Submission Form

2. Note that AutismDx Autism Diagnostic Testing has a mandatory statement of informed consent. It is attached as a fourth page to the above form.

OR

For Cardiology Genetics: Genetic testing for inherited cardiac disorders...

1. Use the 3-page requisition form called: Cardiology Genetics Sample Submission Form

2. Note that Cardiology Genetics - has a mandatory statement of informed consent. It is attached as a third page to the above.

3. Use this word template for Medical necessity letter: Medical necessity letter template
OR


For Genetic Testing for Neurological Disorders…

1. Use the requisition form called: Neurology Disorders Test Requisition Form

2. Note that Genetic Testing for Neurological Disorders has a mandatory clinical information form and a statement of informed consent. They are attached as the third and the fifth page to the above form respectively.

OR


For Prenatal Genetic Testing...

1. Use the 4-page requisition form called: Prenatal Genetics Test Requisition Form

2. Note that the Prenatal Genetics Testing form has a mandatory statement of informed consent on the fourth page of the above form.

OR


For ExonArrayDx...

1. Use the 3-page requisition form called: General Test Requisition Form

2. Note that ExonArrayDx testing has a mandatory statement of informed consent. It is attached as the second page to the above form.



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