Prior Authorization Form - Priority Health

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Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring Prior Authorization
Reset Form
Fax Form To: 616 942-0024
General Genetic Testing
(including Breast and Ovarian Cancer Screening)
Please refer to
Genetics: Counseling, Testing and Screening Medical Policy #91540
for additional information.
Member:
Date: __________________
Last name: ______________________________________________
First name: ______________________________________
Address: _________________________________________________________________________________________________
ID #: ___________________________________________________
DOB: ___________________________________________
Provider:
Name of provider ordering testing: _________________________________________________ Tax ID: ____________________
Contact name: __________________________________________
Phone: __________________ Fax: __________________
Patient Counseling* (must be completed prior to request):
Name of certified *genetic counselor or medical geneticist: __________________________________________________________
Clinic/Facility: _________________________________________________________ Date of counseling: __________________
Contact name: __________________________________________
Phone: ___________________ Fax: __________________
*See
Genetics: Counseling, Testing, Screening Medical Policy #91540
for specific test criteria and genetic counseling
requirements.
Test Requested:
Name of specific test(s):
CPT code(s): ______________________________________________________________________________________________
ICD-9 code(s): _____________________________________________________________________________________________
Directed To:
Facility/Laboratory: _______________________________________
Tax ID#: ________________________________________
Address: _________________________________________________________________________________________________
Contact name: ___________________________________________
Phone: ___________________ Fax: __________________
Member’s personal clinical history related to testing being requested:
Required supportive documentation must include summary notes from a board certified genetic counselor or medical geneticist (not
affiliated with the testing lab) and pedigree.
Family history related to testing being ordered if applicable (please indicate if relationship to member
is maternal or paternal, i.e. maternal aunt, paternal cousin):
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Other relevant information related to testing being ordered:
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May 2014

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