Get Neurology Test Requisition Form - Ambry Genetics

Filling out the Neurology Test Requisition Form from Ambry Genetics is a straightforward process that requires careful attention to detail. This guide will assist you through each section of the form to ensure that all necessary information is accurately provided for effective processing.

Follow the steps to complete the form seamlessly.

1. Press the ‘Get Form’ button to access the Neurology Test Requisition Form and open it in your preferred editor.
2. Begin with the ordering checklist section. Here, you may provide a Letter of Medical Necessity, list ICD-9 Codes, and fill out the clinician and patient signatures along with a copy of the patient’s insurance card if available.
3. Next, move to the patient information section. Fill in the patient's last name, first name, middle initial, date of birth (in MM/DD/YY format), street address, city, state, zip code, preferred contact phone number, gender, ethnicity, and date of death if applicable.
4. In the specimen information section, provide the collection date and specify the specimen type by selecting from options such as blood (EDTA preferred), saliva (adult/pediatric), DNA, etc. Ensure to include the specimen ID if available.
5. Fill out the ordering physician and/or licensed medical professional details including their name, facility name, NPI number, address, phone, fax, and email.
6. Complete the confirmation of informed consent and medical necessity by certifying that the undersigned is authorized to order genetic testing. Indicate if the patient consents to their sample being used for research.
7. Proceed to the insurance billing section. Include a copy of both sides of the insurance card and specify the patient's relation to the policyholder, the policyholder's name and date of birth, and the insurance company details.
8. In the patient payment section, choose your payment method, provide the necessary details, and indicate the amount to be charged.
9. Complete the sections regarding test indications, previous test history, and any additional information relevant to the testing.
10. Review all entered information for accuracy. Once confirmed, you can save your changes, download, print, or share the filled-out form as needed.

Complete the Neurology Test Requisition Form online today for efficient processing.