Get Genetic Fax Referral Form. Genetic Fax Referral Form

Filling out the genetic fax referral form is an important step in ensuring that patients receive the appropriate cancer risk assessment and genetic counseling. This guide will walk you through each section of the form, providing clear instructions to help you accurately complete it.

Follow the steps to successfully complete the genetic fax referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient information section. Include the patient's name, date of birth, insurance details, phone number, street address, city, state, zip code, and member ID number.
3. Complete the referring provider information section. Enter the referring physician's name, phone number, and obtain their signature.
4. In the reason for referral section, indicate if there was any previous genetic testing by selecting 'Yes' or 'No' and specify the gene if applicable. Document the personal history of cancer, including the cancer type(s) and whether they were positive, negative, or variants, along with ages of diagnosis.
5. Provide details on the family history of cancer. For each family member, list their relationship to the patient, the cancer type(s) they had, ages of diagnosis, and whether they are living.
6. Use the additional details/comments section to include any relevant notes or information that may assist in the referral.
7. After completing all the sections, review the form for accuracy. You can save changes, download, print, or share the form as needed.

Complete your genetic fax referral form online today for a smooth referral process.