Prior Authorization Facsimile Request Form: Genetic Testing for BRCA Mutations for
UnitedHealthcare Commercial Health Plans
Date: ______________________________________
Ordering Physician/TIN number: ______________________________________
Address: ______________________________________
City, State, ZIP: ______________________________________
Member name and member ID number: ______________________________________
Thank you in advance for your cooperation. By supplying the requested information in a timely manner,
you will help simplify this process for your patient. If you have any questions or need more information,
please contact the Provider Services number on the back of the member’s ID card.
Please complete Part B of this form for all members requesting prior authorization of genetic testing for
BRCA mutations. Genetic counseling (Part A) is required if the member’s Plan requires covered health
services to be medically necessary. Please include the following clinical documentation with your request,
if applicable:
1. Clinical notes documenting the genetic counseling encounter, including:
Personal history of cancer when applicable (please include cancer type and age of diagnosis)
Three-generation pedigree, including all cancers with age of diagnosis in maternal and paternal blood
relatives; for prostate cancer, the Gleason score should be included
Ethnicity/ancestry (include if the member is Ashkenazi Jewish or from ethnic groups associated with
founder mutations)
2. Part A: Genetic Counseling Attestation Form (to be completed by an independent
genetics care provider)
Unauthorized interception of this facsimile could be a violation of Federal and State Law . If you have received this
privileged information in error, please contact us by phone immediately to arrange for return of the documents. If you
have received this correspondence in error, please notify the sender at once and destroy any copies. This
correspondence is to be used only by the person or entity for w hom it is intended and may contain information that is
privileged and confidential, the disclosure of w hich is governed by applicable law .
Doc#: PCA18831_20151215
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