o Advanced genetics nurse
o Genetic clinical nurse
o Advanced practice nurse in genetics
o A board-eligible or board-certified clinical geneticist
o A physician with experience in cancer genetics (defined as providing cancer risk
assessment on a regular basis and having received specialized ongoing training in cancer
genetics. Educational seminars offered by commercial laboratories about how to perform
genetic testing are not considered adequate training for cancer risk assessment and
genetic counseling).
______________________________________
Signature:
______________________________________
Date:
Genetic counseling by an independent (i.e., not employed by a genetic testing lab) genetics care provider
is required before genetic testing for BRCA mutations so the member being tested is informed about the
benefits and limitations of a specific genetic test. Genetics care providers employed by or contracted with
a laboratory that is part of an integrated health system that routinely delivers health care services beyond
laboratory testing itself are considered independent. Genetic testing for BRCA mutations requires
documentation of medical necessity by one of the following genetics care providers who has evaluated
the member and intends to engage in post-test follow-up counseling:
Board-eligible or board-certified genetic counselor
Advanced genetics nurse
Genetic clinical nurse
Advanced practice nurse in genetics
A board-eligible or board-certified clinical geneticist
A physician with experience in cancer genetics (defined as providing cancer risk assessment on a
regular basis and having received specialized ongoing training in cancer genetics. Educational
seminars offered by commercial laboratories about how to perform genetic testing are not
considered adequate training for cancer risk assessment and genetic counseling).
Part B:
______________________________________
GeneDx
Laboratory name:
207 Perry Parkway
______________________________________
Address:
Gaithersburg, MD, 20877
______________________________________
City, State, ZIP:
______________________________________
20-5446298
TIN:
______________________________________
Laboratory test name:
______________________________________
Date of service (date of sample collection):
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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