Fillable Genetic Testing Information Request Form (UMR)

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Genetic Testing Information Request Form (UMR)

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The Genetic Testing Information Request Form (UMR) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 10 other fields

Country of origin: US
File type: PDF

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1
Genetic Testing Information Request Form
To: UMR Prior Authorization From:
Fax: 866-912-8464 Fax:
Case #:
Phone:
Pages (including cover):
Comments:
Please see the information form below. This information is required in order to review the
requested procedure against the medical policy. The information will assist us in providing a
timely determination of coverage for your patient’s request.
An accurate decision cannot be made without this information.
Thank You,
UnitedHealthcare policies can be viewed in detail at: www.unitedhealthcareonline.com under Policies and
Protocols, then Medical and Drug Policies.
CONFIDENTIALITY NOTICE: Information accompanying this facsimile is considered to be UnitedHealthcare’s confidential
and/or proprietary business information. Consequently, this information may be used only by the person or entity to which it is
addressed. Such recipient shall be liable for using and protecting UnitedHealthcare's information from further disclosure or
misuse, consistent with applicable contract and/or law. The information you have received may contain protected health
information (PHI) and must be handled according to applicable state and federal laws, including, but not limited to
HIPAA. Individuals who misuse such information may be subject to both civil and criminal penalties. If you believe you received
this information in error, please contact the sender immediately.
2
Patient’s Full Name:
Date of birth:
Member ID:
Person completing the form:
• Please include:
o Relevant personal history (signs/symptoms)
o Any relevant family history
o Prior lab results, if applicable in clinical documentation
• Indicate below:
o The name(s) of genetic test(s) being requested and
o Associated codes
o Specimen type (if not blood)
• Please complete and fax the form with clinical documentation
Please Note: The submitted codes should not be unbundled. If codes are part of a
panel, the request needs to be submitted as a single code for that panel. Failure to do
so may cause delays and or adverse determinations.
Genetic Panel Name:
Genetic Panel CPT Code:
Complete Below If Request is Not Part of a Panel:
Reason Test is Not Part of Panel:
Name of Genetic Test(s)
Associated CPT Code (s):
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Genetic Testing Information Request Form (UMR)

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Completed 2 January 2022

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