Get Ut Genetic Testing Prior Authorization Request Form 2017

Filling out the UT Genetic Testing Prior Authorization Request Form is an essential process for obtaining necessary genetic tests for patients. This guide provides a clear, step-by-step approach to completing the form accurately and efficiently online.

Follow the steps to effectively complete the form online:

1. Press the ‘Get Form’ button to acquire the form, allowing you to access it digitally.
2. Begin with the member information section. Enter the member's name, identifying number, date of birth, and age. Specify the date of the request and include the requested dates of service.
3. Indicate whether this is a retroactive request by selecting ‘Yes’ or ‘No’. If ‘Yes’ is selected, provide the reason for the retroactive request.
4. In the provider information section, fill in the names, addresses, and NPI numbers for both the requesting provider and laboratory. Ensure to provide contact details, including phone and fax numbers.
5. Complete the required clinical information. Enter the appropriate ICD-10 codes with their descriptions. Fill in the HCPCS code and description, if applicable.
6. List the genes to be tested, if they are not already identified by the HCPCS code. Describe the type of test(s) being requested, such as mutation panel or full gene sequencing.
7. Provide detailed descriptions of the clinical validity and utility of the tests, including analytics and past treatment outcomes.
8. Include information about the patient’s clinical and physical features related to the mutation.
9. Detail any relevant family history and describe findings specific to the patient.
10. Outline past treatments that have been provided and summarize previous test results that justify the need for this new genetic test.
11. Clarify the current treatment plan and explain how the knowledge of the genetic defect will influence future management, intervention, and medication.
12. Finally, the physician must sign and date the form to validate the request.
13. Once all sections are completed, you may save, download, print, or share the form as needed.

Complete your UT Genetic Testing Prior Authorization Request Form online today to ensure timely and accurate processing.