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 Insurance Authorization Request Form for Genetic Testing
Forms must be completed/ submitted prior to leaving our website

Forms must be completed/ submitted prior to leaving our website

Insurance Authorization Request Form for Genetic Testing

Insurance Authorization Request Form for Genetic Testing

1. Today's Date(Month/Day/Year)

1. Today's Date(Month/Day/Year)
2. Name

2. Name
3. For what testing are your seeking insurance authorization?

3. For what testing are your seeking insurance authorization?
4. Why?

4. Why?
5. What have you already done to obtain approval? Explain.

5. What have you already done to obtain approval? Explain.
6. Have any of your physicians been able to help? Explain.

6. Have any of your physicians been able to help? Explain.
7. Why do you feel you need this testing?

7. Why do you feel you need this testing?
8. How do you feel that testing can help you?

8. How do you feel that testing can help you?
9. Does your doctor(s) feel that genetic testing could affect your care?

9. Does your doctor(s) feel that genetic testing could affect your care?
10. Please list your physician who will order testing

10. Please list your physician who will order testing

This physician will be notiifed with the results of this authorization request and recieve your genetic test report. We will work with him in obtaining test authorization, test coordination and interpreting your genetic test results.
11. Doctor's Name

11. Doctor's Name
12. Specialty

12. Specialty
13. Address

13. Address
14. Phone Number

14. Phone Number
15. Fax Number

15. Fax Number
16. Insurance Card Information

16. Insurance Card Information

Please fax a copy of both sides of your insurance card to 888-204-5975 OR take a picture/scan both sides and email to us at insurance@geneticcounselingservices.com
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18. Verifier

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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing.  Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing.  Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists,  in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists. 

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