Home
Insurance Authorization
  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
17.  Heading

17. Heading

18.  Verifier

18. Verifier

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.
Your Code
Enter Code


Copyright © Genetic Counseling Services Schenectady, New York
info@geneticcounselingservices.com