Providers Forms

If you’re a healthcare provider, you can easily find and download the forms most frequently used during the genetic testing process below.

The quickest way to place an order is via our online provider portal. Alternatively, you may place an order through client services at 301-519-2100, option 3 or submit a Test Requisition Form (TRF) via email to support@genedx.com or fax (201-421-2010).

Please note: GeneDx does not accept orders or specimens from the UK or European Union (EU) countries at this time.

Test Requisition Forms (TRF)

Add/change test authorization form

XomeDx^® test requisition

GenomeSeqDx test requisition

Rapid sequencing test requisition form

Trio/Duo testing family member requisition

Cardiology test requisition

Cytogenetics test requisition

Hereditary cancer test requisition

Hereditary cancer test requisition (for non-US clients)

Mitochondrial/metabolic disorders test requisition

Neurology test requisition

Ophthalmology/audiology test requisition

Prenatal test requisition

Prenatal XomeDx^® test requisition

Rare disorders test requisition

Consent Forms

GeneDx’s standard patient informed consent form can be found below, in multiple languages. Our patient informed consent form is also included with all of our test requisition forms, as the last two pages.

English informed consent

French informed consent

Arabic informed consent

Spanish informed consent

Letters of medical necessity

Cardiology

Arrhythmia Panel letter of medical necessity

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Panel letter of medical necessity

Brugada Syndrome (BrS) letter of medical necessity

Cardiomyopathy Panel letter of medical necessity

Combined Cardiac Panel letter of medical necessity

Dilated Cardiomyopathy (DCM) letter of medical necessity

Ehlers Danlos Panel letter of medical necessity

FBN1 gene sequencing & DEL/DUP letter of medical necessity

Heritable Disorders of Connective Tissue (HDCT) Panel…

Hypertrophic Cardiomyopathy (HCM) letter of medical necessity

Long QT Syndrome (LQTS) letter of medical necessity

Marfan Syndrome/TAAD letter of medical necessity

Stickler Syndrome Panel letter of medical necessity

Sudden Cardiac Arrest (SCA) Arrhythmia Panel letter of…

Neurology

Autism/ID Panel letter of medical necessity

Autism/Intellectual Disability (ID) Xpanded Panel letter of me…

Chromosomal Microarray (CMA) letter of medical necessity

Comprehensive Epilepsy Panel letter of medical necessity

Epilepsy Del/Dup Panel letter of medical necessity

Epi Xpanded^® Panel letter of medical necessity

Hemiplegic Migraine Panel letter of medical necessity

Mitochondrial Testing letter of medical necessity

Rett/Angelman Syndrome Panel letter of medical necessity

Tuberous Sclerosis Panel letter of medical necessity

Whole Exome Sequencing (WES)

XomeDx^® – Proband Only letter of medical necessity

XomeDx^® – Trio letter of medical necessity

XomeDx^® Plus – Duo letter of medical necessity

XomeDx^® – Duo letter of medical necessity

XomeDx^® Plus – Proband Only letter of medical necessity

XomeDx^® Plus – Trio letter of medical necessity

Insurance & Financial Assistance

Aetna

Aetna genetic testing policies

Aetna medical precertification form for BRCA

Aetna medical precertification form for WES

Carelon

Carelon clinical guidelines – genetic testing

Cigna

Cigna Whole Exome Sequencing and Whole Genome Sequencing Recommendation Form

Cigna genetic testing & counseling resources

Cigna genetic counselor recommendation

Cigna precertification

Evicore

Evicore health plans – laboratory managementolicies

Horizon BCBS NJ

Horizon BCBS NJ genetic testing policies

Humana

Humana coverage policy homepage

United Healthcare

United Healthcare genetic testing policies

United Healthcare genetic & molecular lab prior authorizations

Medicare

Medicare national coverage determinations (NCDs)

Medicare local coverage determinations (LCDs)

Advanced beneficiary notice (ABN) homepage & forms

Medicare coverage database

Financial Assistance Program Forms

At GeneDx, we firmly believe that everyone deserves access to vital insights from genetic testing, regardless of their financial situation which is why we offer a robust Financial Assistance Program to help reduce the potential out-of-pocket costs associated with testing.

The program has broad eligibility criteria, meaning that most patients will qualify for some level of financial assistance.

Please send the form below to your patient and have them return the completed, signed application to billing@genedx.com.

Financial Assistance Application (English)

Financial Assistance Application (Spanish)

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

Alabama EPSDT form

California EPSDT form

Indiana EPSDT form

Massachusetts EPSDT form

Texas EPSDT form

Sample templates

Exome template – establishing medical necessity

Genome template – establishing medical necessity

Medical Records Request

In order to receive copies of patient medical records for patients who have received genetic testing that was ordered by another healthcare provider (e.g., genetic test results), please contact our Customer Service team at (888) 729-1206, option 3, or email support@genedx.com. To request raw data on patients (e.g., sequencing files), please contact the data send out team at clinicalgenomicsdata@genedx.com.