Get Verifi Test Form

Filling out the Verifi Test Form online is a crucial step in ensuring that appropriate prenatal testing is conducted. This guide will provide you with clear and supportive instructions on how to navigate each section of the form to ensure accurate completion.

Follow the steps to complete the Verifi Test Form accurately

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling in the clinician's details in the 'Account / Ordering Clinician' section. Ensure to provide the physician's name, genetic counselor's name, account name, account number, address, city, state, ZIP code, phone, and fax number where applicable.
3. In the 'Patient Information' section, provide the patient's name. Input the last name, first name, and middle initial (if available). Attach a face sheet or label if available for ease.
4. Fill out the patient's address, including the apartment number if applicable, and their date of birth in the mm/dd/yyyy format, along with their city, state, and ZIP code.
5. In the 'Test Information' section, choose only one Verifi test option for singleton or twin pregnancy. Complete the section by identifying the specific test required.
6. Indicate the test indications related to the pregnancy and provide the corresponding ICD-9 code as necessary.
7. Complete the 'Clinical Information' section by noting the gestational age, advanced maternal age, date of blood draw, and any comments relevant to the medical necessity for the test.
8. Ensure the clinician confirms the order by signing and dating the form in the appropriate sections.
9. In the billing information section, specify the payment method, relationship of the patient to the insured, and if necessary, fill in the credit card details or other payment information.
10. In the 'Patient Consent' section, the patient must sign and date the form, confirming their understanding of the test's purpose and implications.
11. Once the form is fully completed, you can save the changes, download, print, or share the form as needed.

Complete your documents online confidently by following these steps.