Get Preferredone Genetic Testing For Heritable Conditions Prior Authorization Form 2019-2025

The PreferredOne genetic testing for heritable conditions prior authorization form is essential for obtaining the necessary approval for genetic testing services. This guide will help users navigate the process of filling out the form online, ensuring that all required information is accurately provided.

Follow the steps to complete the form accurately online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient's name, PreferredOne ID number, date of birth, and ICD 10 diagnosis code in the designated fields.
3. Enter the ordering provider's signature, their procedure code(s), date of service, and the date of lab draw in the appropriate sections.
4. Provide the ordering provider's first and last name, NPI number, clinic name, address, city, phone, and fax details.
5. Input the servicing provider's name (laboratory), including their NPI number, address, phone, city, state, and zip code.
6. List the gene(s) being tested in the specified field, followed by the disease, sickness, or defect being tested for.
7. Indicate whether the member displays clinical features of an inheritable disease by checking the appropriate box.
8. If applicable, ensure that all conditions are checked that support the request for genetic testing, including history, physical examination, and consent documentation.
9. Detail how the results of the test directly impact the current treatment or management by selecting the appropriate actions and explaining as necessary.
10. Check any additional applicable boxes, providing relevant details regarding familial variants or testing requests.
11. Finally, review all entries for accuracy, save changes, and choose to download, print, or share the completed form as needed.

Start completing the PreferredOne genetic testing prior authorization form online today to ensure timely processing.