Ethnicity/ancestry:
V. BRCA1 and BRCA2 testing is proven and medically necessary for men with a personal history of
prostate cancer (Gleason score ≥7) at any age and at least one close blood relative on the same side
of the family with breast (ages 50 and younger), ovarian, pancreatic and/or prostate cancer (Gleason
score ≥7) at any age.
Please indicate family members including which side of family (i.e., maternal or paternal),
cancer including age and/or Gleason score:
VI. BRCA1 and BRCA2 testing is proven and medically necessary for men with a personal history of
breast cancer.
VII. BRCA1 and BRCA2 screening tests are proven and medically necessary for men and women
without a personal history of breast or ovarian cancer with at least one of the following familial risk
factors only when there are no family members affected with a BRCA-associated cancer available
for testing (see note below). Please check all that apply:
At least one first- or second-degree blood relative meeting any of the above criteria
(I-V)
Please indicate family members including which side of family (i.e., maternal or paternal):
At least one third-degree blood relative with breast cancer and/or ovarian cancer who has at
least two close blood relatives with breast cancer (at least one with breast cancer at ages 50 or
younger) and/or ovarian cancer
Please indicate family members including which side of family (i.e., maternal or
paternal):
A known BRCA1/BRCA2 mutation in a blood relative (defined as first-, second- or third-
degree relative). Testing should be targeted to the known BRCA1/BRCA2 mutation in the
family. Further BRCA1/BRCA2 testing should only be pursued if the results are negative and
the member otherwise meets testing criteria.
Please indicate family members including which side of family (i.e., maternal or
paternal):
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 .
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