Get Exomenexttm Proband Test Requisition Form - Ambry Genetics

Filling out the ExomeNext™ Proband Test Requisition Form is a crucial step in accessing genetic testing services through Ambry Genetics. This guide provides clear and detailed instructions to help users navigate the form accurately and efficiently.

Follow the steps to successfully complete the requisition form.

1. Press the ‘Get Form’ button to download the ExomeNext™ Proband Test Requisition Form and open it in your preferred document editor.
2. Select one test option by marking either the 'ExomeNext' for insurance billing or 'ExomeNext Rapid' for institutional billing only.
3. Indicate whether you wish to opt out of the ACMG Secondary Findings Minimum List by checking the appropriate box.
4. Fill in the patient information section, including the last name, first name, middle initial, date of birth, street address, city, state, preferred contact phone number, gender, ethnicity, and date of death if applicable.
5. Complete the specimen information fields, providing the collection date, specimen ID, medical record number (MRN), and type of specimen. Ensure you adhere to the guidelines for specimen acceptance.
6. In the ordering physician section, enter the name of the licensed medical professional, facility name, NPI number, address, phone, fax, email, and the name of any additional medical professionals involved.
7. Certify the confirmation of informed consent and medical necessity by signing and dating the form. Ensure that all required details about consent for research use are clearly identified.
8. Complete the payment/billing information section, indicating whether insurance or institutional billing will be used, along with all necessary payment details.
9. Select applicable ICD-9 codes relevant to the patient’s case and ensure that all checkboxes are filled accurately.
10. Verify that all family members needed for testing are identified in the family members section and provide the required documents as listed.
11. Finally, review the entire requisition form for completeness and accuracy. Once satisfied, you can save your changes, download the completed form, print it, or share it as required.

Complete the ExomeNext™ Proband Test Requisition Form online to facilitate the genetic testing process.