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Clients without computer access may contact us by phone at 888-260-6543
Forms must be completed/ submitted prior to leaving our website
Insurance Authorization Request Form for Genetic Testing
1. Today's Date(Month/Day/Year)
3. For what testing are your seeking insurance authorization?
5. What have you already done to obtain approval? Explain.
6. Have any of your physicians been able to help? Explain.
7. Why do you feel you need this testing?
8. How do you feel that testing can help you?
9. Does your doctor(s) feel that genetic testing could affect your care?
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
14. Phone Number
15. Fax Number
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 firstname.lastname@example.org
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