Genetic Testing Pre-Authorization Request Form
Patient Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Member ID
Phone Number
Ordering Provider Information
Provider Name
NPI Number
Practice Name
Phone Number
Laboratory Information
Lab Name
Lab Contact Number
Test Information
Test Name
CPT Code(s)
Indication for Testing / Clinical Rationale
ICD-10 Code(s)
Supporting Documentation
Relevant Medical History
Previous Genetic Testing (if applicable)
Additional Comments