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Referral Form For Providers

Referral Form For Providers


Physicians, Genetic Counselors, and other health care providers who wish to provide (anonymous, by initial, by first name and last initial, or actual; please be aware that this website system is encrypted and secure, although we cannot guarantee your own system) information about their patients whom they are referring or have referred to us,   may email us at info@geneticcounselingservices.com or submit the referral information below. 

Please be aware that we will review insurance eligibility for any referrals and help each patient to identify all of the no cost (except Co-pay) options that are available to them, BEFORE offering any appointments.  Referral of your patient at this time-- is no obligation to your service or to your patient.  The information which you provide here will facilitate genetic counseling for your patient if they choose to have genetic counseling with Genetic Counseling Services.   

  Referral Form For Providers or Insurers

Referral Form For Providers or Insurers

1.  Name of Provider

1. Name of Provider


2.  Provider's Phone Number

2. Provider's Phone Number


3.  Provider's e-mail address

3. Provider's e-mail address

Optional.  But you must type something in this area in order to submit this form.  Type: unknown, or not available. 

4.  Patient's Insurance

4. Patient's Insurance


5.  Provider's affiliation (hospital or practice)

5. Provider's affiliation (hospital or practice)


6.  Patient's Name or Initials ( Ex: JFK  or JK )

6. Patient's Name or Initials ( Ex: JFK or JK )


7.  Patient's email address

7. Patient's email address


8.  Patient Age and medical information

8. Patient Age and medical information


9.  Patient Family History or Information of Concern

9. Patient Family History or Information of Concern


10.  Is there anything you would like to ask or tell us about this case?

10. Is there anything you would like to ask or tell us about this case?


11.  Would you like us to call you to discuss this referral?

11. Would you like us to call you to discuss this referral?

Otherwise we will email you to notify you that we have received this request. Which do you prefer?

12.  Patient Contact Information

12. Patient Contact Information

 Please provide phone and email information if available and fax the patient demographic to us at 888-204-5975 after submitting this form. Thank you.  

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