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Insurer Referral Form to Request Case Comment

1.  Name of Requestor

1. Name of Requestor


2.  Phone Number of Individual Making this Request

2. Phone Number of Individual Making this Request


3.  E-mail address of Requestor

3. E-mail address of Requestor


4.  Affiliation ( Clinic or Insurer)

4. Affiliation ( Clinic or Insurer)


5.  Case Identifying Name, Initials or Number (Ex: JFK  or 102)

5. Case Identifying Name, Initials or Number (Ex: JFK or 102)


6.  Patient Age and medical information

6. Patient Age and medical information


7.  Patient Family History or Information of Concern

7. Patient Family History or Information of Concern


8.  What Genetic Information would help you most ?

8. What Genetic Information would help you most ?


9.  What is the best way to reach you about this referral?

9. What is the best way to reach you about this referral?

Telephone (if there is more than one number please tell us), e-mail, or pager (provide instructions here)

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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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