Download - Genetic Counseling Referral Cancer Genetic …...2016 Informed edical Decisions Inc. Genetic Counseling Referral Date _____ Patient Information* (*all fields are required. Mark "No

Patient Information* (*all fields are required. Mark "No Email" if the patient doesn't have email.)

Laboratory Information

Reason for Referral

Patient Documentation - Fax with Referral

Physician Information

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Billing2

version 1 - July 18, 2016

Name:______________________________________________________________ Date of Birth:____/____/________

□Phone:_____________________ □Cell:____________________ Email:___________________________________

Surgery pending date:___/___/_____ Primary language spoken: □English □Spanish □Other:____________

________________________________Medical Center/Practice

________________________________Referring Provider

________________________________NPI

________________________________Practice Contact

________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip

________________________________Referring Provider's Signature

a. Clinical. Please include the following (if performed)

□ Pathology reports □ Patient genetic test results

□ Family member genetic test results □ Test request form

b. Patient face sheet (Demographics).

c. Insurance documentation. A copy of front and back of the patient's insurance card.

Sample collection date:____________________________

Sample sent to (Lab name):_________________________________________________________________

Specific test ordered:______________________________________________________________________

PREFERRED PREFERRED

□ Bill to Patient Insurance □ Other (please explain):________________________________________

□ cancer

□ cardiac

□ pediatric (e.g. whole exome sequencing and chromosome microarray)

Pre-test genetic counseling for the following genetic testing types. Please check one to ensure scheduling with the appropriate genetics specialist.

□ reproductive (e.g. carrier screening, NIPS, chromosome microarray)

□ ocular

□ neurology

Fax completed form to:

7

For questions about InformedDNA services, please call

800-975-4819

Fax completed form to the lab and they will forward to InformedDNA.

© 2016 Informed Medical Decisions, Inc.

Genetic Counseling ReferralDate ___________________________



Reason for Referral



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Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



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3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



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3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



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3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819



Genetic Counseling ReferralDate ___________________________Patient Information* (*all fields are required. Mark "No Email" if the patient doesn't have email.)


Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819






Reason for Referral



1

3

4

5

6

Billing2



□Phone:_____________________ □Cell:____________________ Email:___________________________________




________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip










PREFERRED PREFERRED


□ cancer

□ cardiac




□ ocular

□ neurology


7


800-975-4819




Place form in test kit for:

Patient Information

Billing

Reason for Referral


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3

2

7

8


Patient Documentation - Fax with Referral to InformedDNA at 760-203-1194 (surgery pending only)

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Cancer Genetic Counseling Referral

(760)203-1194

Name:____________________________________________________ Date of Birth:____ /____ /_________

Phone:_____________________ Cell:____________________ E-mail:________________________________


Surgery pending date*:____ /____ /_________

Date ___________________________

□ Bill to Patient Insurance □ Self pay

□ □ Breast

□ □ Ovarian

□ □ Colon (or rectal)

□ □ Uterine/endometrial (not cervical)

□ □ Pancreatic

□ □ Stomach or intestinal

□ □ Kidney or urinary tract

□ □ Thyroid

□ □ Melanoma

□ □ Colon polyps

□ □ Known cancer gene mutation (such as BRCA1/2 or HNPCC/Lynch genes or others)

□ □ Other (please specify) ____________________

________________________________________________

PATIENT PATIENTFAMILyMEMBER

FAMILyMEMBER

Personal and/or family history of cancer. What type? (check all that apply)


□ Pathology reports (cancer and/or polyps) □ Patient genetic test results□ Family member genetic test results □ Test request form IF sAmPLe CoLLeCteD

b. Insurance documentation. A copy of front and back of the patient's insurance card.** Used to verify the patient's benefits.



________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________City State Zip


The lab provides a copy of the patient's result to InformedDNA for Post-Test Genetic Counseling

sample collected. Collection date:____/____/________ □ Sample sent to GeneDx Laboratories

□ Referred for POST-TEST Genetic Counseling only ____/____/________ (results expected to be complete)

* Checking this box and signing in box 6 indicates that I have performed genetic counseling and patient informed consent was obtained. The patient isbeing referred to InformedDNA for POST-TEST Genetic Counseling only. (Referring physician signature required)

SAL

12/05/2014

Place form in test kit for:

Patient Information

Billing

Reason for Referral


1

3

2

7

8


Patient Documentation - Fax with Referral to InformedDNA at 760-203-1194 (surgery pending only)

5

4


6


(760)203-1194


Phone:_____________________ Cell:____________________ E-mail:________________________________


Surgery pending date*:____ /____ /_________

Date ___________________________

□ Bill to Patient Insurance □ Self pay

□ □ Breast

□ □ Ovarian

□ □ Colon (or rectal)

□ □ Uterine/endometrial (not cervical)

□ □ Pancreatic

□ □ Stomach or intestinal

□ □ Kidney or urinary tract

□ □ Thyroid

□ □ Melanoma

□ □ Colon polyps

□ □ Known cancer gene mutation (such as BRCA1/2 or HNPCC/Lynch genes or others)

□ □ Other (please specify) ____________________

________________________________________________

PATIENT PATIENTFAMILyMEMBER

FAMILyMEMBER

Personal and/or family history of cancer. What type? (check all that apply)


□ Pathology reports (cancer and/or polyps) □ Patient genetic test results□ Family member genetic test results □ Test request form IF sAmPLe CoLLeCteD

b. Insurance documentation. A copy of front and back of the patient's insurance card.** Used to verify the patient's benefits.



________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________City State Zip


The lab provides a copy of the patient's result to InformedDNA for Post-Test Genetic Counseling

sample collected. Collection date:____/____/________ □ Sample sent to GeneDx Laboratories

□ Referred for POST-TEST Genetic Counseling only ____/____/________ (results expected to be complete)

* Checking this box and signing in box 6 indicates that I have performed genetic counseling and patient informed consent was obtained. The patient isbeing referred to InformedDNA for POST-TEST Genetic Counseling only. (Referring physician signature required)

SAL

12/05/2014

8


(760)203-1194


Phone:___________________ Cell:__________________E-mail:________________________________________________________________

Medical Center/Practice


________________________________NPI


________________ _______________ Phone Fax

________________________________E-mail

________________________________Address

_________________ _____ ________City State Zip


Questions about our

services?

800-975-4819#W001


Surgery pending date:____ /____ /____

Date _____ / _____ / __________

□ Bill to Patient Insurance □ Other (please explain):__________________________________________

□ Personal history of cancer

□ Family history of cancer

□□ □


□ Pathology reports (cancer and/or polyps) □ Patient genetic test results□ Family member genetic test results □ Test request form IF SAMPLE COLLECTED


c. Insurance documentation. A copy of the front and back of the patient's insurance card.

Sample collected□ Yes Collection date:_____________ Sample sent to (Lab name):________________

□ No Lab preferences (If not already collected):________________________________

01/01/2016

Patient Information* (*all fields are required. Mark "No Email" if the patient does not have email.)

Billing




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PREFERRED□Primary language spoken: □English □Spanish □Other _______

PREFERRED□

Reason for Referral (check all that apply)

Patient Documentation - Fax with Referral*InformedDNA considers test quality, cost, insurance network and physician preference when selecting a laboratory.

Specific test being ordered /considered:________________________________________________

List type(s):______________________________________________

List type(s):______________________________________________

Insurance policy requires genetic counseling prior to genetic test authorization

Genetic counseling for hereditary suseptability to breast and/or colon cancer

Other (please specify):______________________□ Known cancer gene mutation in the family

Download - Genetic Counseling Referral Cancer Genetic …...2016 Informed edical Decisions Inc. Genetic Counseling Referral Date _____ Patient Information* (*all fields are required. Mark "No

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