Get Cmgdl Genetic Test Requisition Form Client Account Information Clinical Molecular Genetics

Completing the CMGDL genetic test requisition form online is an essential step for submitting specimens for genetic testing. This guide provides clear instructions for each component of the form to ensure accurate and efficient completion.

Follow the steps to fill out the form correctly and ensure a smooth submission process.

1. Click ‘Get Form’ button to obtain the CMGDL genetic test requisition form and open it in your document editor.
2. Enter the required client account information in the designated fields—this includes client name, fax number, client number, telephone number, medical record number, and authorization number. Ensure all information is printed clearly.
3. Fill out the specimen information section by including the collection date, time, collector's name, specimen source, and sample type submitted. Use the provided option for whole blood collection.
4. Complete the patient information section by providing the patient's last and first name, address, city, state, zip code, social security number, date of birth, sex, and ICD-9 code. Ensure all necessary details are included.
5. Input the ordering physician information. This includes the test order date, the doctor's name, NPI number, contact information, and facility lab information. Make sure this section is legibly filled out.
6. Describe the patient’s insurance information if applicable. Include the insured’s name, the type of insurance plan, insurance company details, and relationship to the insured.
7. Proceed to indicate any customer requests for duplicate reports, if necessary, and provide the relevant billing or contact information.
8. Sign and date the form where indicated, confirming understanding and consent for the genetic testing protocol, including financial responsibilities.
9. After thoroughly reviewing all filled sections for accuracy, save your changes, then download, print, or share the completed form as required.

Begin filling out the CMGDL genetic test requisition form online to ensure a streamlined process for your genetic testing needs.