Get Cigna Whole Exome Sequencing Recommendation Form 2016-2025

Completing the Cigna Whole Exome Sequencing Recommendation Form online requires attention to detail and an understanding of the required information. This guide offers a comprehensive walkthrough of the form's components to assist you in successfully submitting your request.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by providing the customer (patient) information. Fill in the following fields: Name, Cigna customer ID, Date of birth, and Date of consultation.
3. Enter the ordering health care professional's information. Include their Name, Street address, City, State ZIP, Specialty, Taxpayer Identification Number (TIN), Telephone, and Fax.
4. If applicable, fill out the information for a clinical geneticist or genetic counselor. Provide their Name, Street address, Telephone, City, State ZIP, and Fax.
5. Next, provide rendering laboratory information, including Name, Street address, City, State ZIP, Taxpayer Identification Number (TIN), Telephone, and Fax.
6. List the relevant ICD-10 codes in the designated section for diagnosis codes.
7. Complete the requested test information by including the Test name, CPT code(s), and the List price.
8. Indicate whether the patient's phenotype is likely genetic by checking the appropriate options and providing any necessary specifications.
9. List the differential diagnoses and key gene(s) of interest in the provided fields.
10. Outline proposed changes to medical management specific to the patient based on WES results, if applicable.
11. If WES is not performed, specify any recommended genetic tests, their names, and list prices.
12. Note any recommended follow-up procedures, including their names and frequency, if WES is not conducted.
13. Initial in the provided space to attest that no clinically available single gene or panel test adequately addresses the patient's symptoms.
14. Choose a recommendation based on the criteria given, and provide any additional explanations or reasons as needed.
15. Affirm your qualifications and attach the necessary documents. Confirm that you logged the three-generation pedigree, ordering health care professional’s laboratory requisition form, and genetic evaluation documentation.
16. Lastly, fill in your signature and the date, and review the information for accuracy before submission.
17. After completing all necessary fields, save your changes, and consider downloading, printing, or sharing the completed form as required.

Complete the Cigna Whole Exome Sequencing Recommendation Form online to ensure your request is processed smoothly.