O not meet the definition of Medically Urgent, however, are deemed to be time sensitive by one or more of the affected parties.) Pre-Service Medically Urgent (Attending Physician Signature REQUIRED Below) (Medically Urgent In the opinion of the attending physician, there is a risk to the member s life, serious bodily injury or pain that cannot otherwise be managed.) Attending Physician Signature: Date: PATIENT DEMOGRAPHICS Patient N.
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How to fill out the Dean Health Plan Genetic Testing online
Filling out the Dean Health Plan Genetic Testing form online is a crucial step for ensuring the proper assessment and approval of genetic tests. This guide provides a clear, step-by-step process to help users complete the form accurately and efficiently.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to obtain and open the Dean Health Plan Genetic Testing form in a designated editor.
- Fill in the patient demographics section. Provide the patient's name, date of birth, member ID, phone number, street address, city, state, and zip code. Ensure all information is accurate to avoid processing delays.
- Complete the referring provider information. Include the provider's name, phone number, street address, fax number, city, state, provider number, zip code, and specialty.
- Input the genetics health care provider information. This includes the name, phone number, street address, fax number, city, state, and zip code of the clinical geneticist, genetic counselor, advanced genetics nurse, or genetic clinical nurse.
- Provide the rendering laboratory information, including the tax payer identification number (TIN), name, street address, city, fax number, state, and zip code.
- Enter clinical information by noting the date(s) of service, diagnosis(es), and corresponding ICD code(s). This information is essential for the review and approval process.
- Complete the test information section. List the clinical history, requested test name(s), and CPT/HCPCS code(s). This step is crucial as CPT/HCPCS codes are required for processing.
- If genetic counseling is required, complete the attached genetic counseling recommendation form as instructed.
- Review all entered information for accuracy. Once confirmed, users can save changes, download, print, or share the completed form as required.
- Fax the completed form to 608-252-0830. If needed, reach out to Dean Health Plan Customer Service at 800-279-1301 for assistance.
Complete your genetic testing authorization form online today to ensure timely processing.
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