Get Dean Health Plan Genetic Testing 2018

Filling out the Dean Health Plan Genetic Testing form online is a straightforward process that requires attention to detail. This guide will walk you through each section of the form to ensure you provide all necessary information correctly.

Follow the steps to accurately complete the genetic testing form.

1. Click ‘Get Form’ button to obtain the genetic testing form and open it for editing.
2. Begin with the patient demographics section. Enter the patient's name, member ID, street address, city, state, date of birth, and phone number in the respective fields.
3. In the referring provider information section, provide the provider's name, street address, city, state, provider number, zip code, phone number, fax number, and specialty.
4. Complete the referred to physician/facility/provider information with the name, street address, city, state, and specialty of the provider to whom the patient is being referred.
5. Under request information, accurately fill in the date(s) of service and include diagnosis codes and applicable CPT codes with descriptions. Provide the number of visits required.
6. Indicate any third-party liability that may apply, including options for workers’ compensation (W/C), motor vehicle accident (MVA), or other.
7. In the test information section, summarize the clinical history, note the genetics counselor or primary contact, and specify the test name and testing lab information including address, phone, and fax.
8. Fill in the cost of the test section by indicating whether the testing lab will bill Dean Health Insurance directly or another institution, along with anticipated sample collection date. If applicable, check the box indicating if the genetics counselor needs a copy of the authorization.
9. Finally, provide the form submitter’s name, phone, and fax number in the designated fields.
10. After reviewing the completed form for accuracy, proceed to save changes. You can download the form, print it, or share it as needed before faxing it to 608-252-0830.

Complete your genetic testing form online to ensure timely processing and care.