genetic counseling referral cancer genetic …...2016 informed edical decisions inc. genetic...
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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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
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
1
3
4
5
6
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 ___________________________
Place form in test kit for:
Patient Information
Billing
Reason for Referral
Fax completed form to:
1
3
2
7
8
Laboratory Information
Patient Documentation - Fax with Referral to InformedDNA at 760-203-1194 (surgery pending only)
5
4
Physician Information
6
Cancer Genetic Counseling Referral
(760)203-1194
Name:____________________________________________________ Date of Birth:____ /____ /_________
Phone:_____________________ Cell:____________________ E-mail:________________________________
© 2015 Informed Medical Decisions, Inc.
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)
a. Clinical. Please include the following (if performed)
□ 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.
________________________________Medical Center/Practice
________________________________Referring Provider
________________________________NPI
________________________________Practice Contact
________________ _______________ Phone Fax
________________________________E-mail
________________________________Address
_________________ _____ ________City State Zip
________________________________Referring Provider's Signature
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
Fax completed form to:
1
3
2
7
8
Laboratory Information
Patient Documentation - Fax with Referral to InformedDNA at 760-203-1194 (surgery pending only)
5
4
Physician Information
6
Cancer Genetic Counseling Referral
(760)203-1194
Name:____________________________________________________ Date of Birth:____ /____ /_________
Phone:_____________________ Cell:____________________ E-mail:________________________________
© 2015 Informed Medical Decisions, Inc.
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)
a. Clinical. Please include the following (if performed)
□ 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.
________________________________Medical Center/Practice
________________________________Referring Provider
________________________________NPI
________________________________Practice Contact
________________ _______________ Phone Fax
________________________________E-mail
________________________________Address
_________________ _____ ________City State Zip
________________________________Referring Provider's Signature
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
Cancer Genetic Counseling Referral
(760)203-1194
Name:____________________________________________________ Date of Birth:____ /____ /_________
Phone:___________________ Cell:__________________E-mail:________________________________________________________________
Medical Center/Practice
________________________________Referring Provider
________________________________NPI
________________________________Practice Contact
________________ _______________ Phone Fax
________________________________E-mail
________________________________Address
_________________ _____ ________City State Zip
________________________________Referring Provider's Signature
Questions about our
services?
800-975-4819#W001
© 2016 Informed Medical Decisions, Inc.
Surgery pending date:____ /____ /____
Date _____ / _____ / __________
□ Bill to Patient Insurance □ Other (please explain):__________________________________________
□ Personal history of cancer
□ Family history of cancer
□□ □
a. Clinical. Please include the following (if performed)
□ Pathology reports (cancer and/or polyps) □ Patient genetic test results□ Family member genetic test results □ Test request form IF SAMPLE COLLECTED
b. Patient face sheet (Demographics).
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
Physician Information
Fax completed form to:
Laboratory Information
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3
2
5
4
6
7
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