We will be calling you within 48 hours to schedule you, once we have received the information below. Returning patients may skip this section, unless we have requested any of the insurance information (1.) or Forms (2.) below.
1. Please forward a copy of the front and back of your medical insurance card. Select any one of 3 ways to do this:
(Patients who opt for self-pay or returning patients, please omit this step and go to number 2.)
- Fax ( after copying to paper) to 888-204-5975
- E-mail a copy of your insurance card to firstname.lastname@example.org
- Take a picture of your insurance card with your phone and send to email@example.com or 1-888-204-5975
- Patients unable to do any of the above should call us at 888-260-6543 prior to appointment.
2. New Patients should complete the following 3 forms for Service Level 1- Initial Assessment to be completed online.
Returning patients should complete any forms that we have requested at this time.
Complete the forms below, only if we have requested such or if you would like us to include this information in your assessment:
- Cancer Risk Assessment ( important if your appointment pertains to Cancer Risk Assessment and/or Cancer Predispositional Testing)
- Medical Records Request
- Myriad Laboratories Authorization Form. ( If your appointment has to do with testing done by Myriad Labs/ this form is an Authorization to Use and Disclose Protected Health Information) THIS FORM MUST BE PRINTED, SIGNED AND FAXED (888-204-5975) and is only necessary if you have previously had genetic testing through Myriad Laboratories and you are seeking genetic counseling with regards to this.
- Please go to Patient Check-In/ Step 2 to make your co-payment now, if your appointment is scheduled within the next day or two. Otherwise please do so on the morning of your appointment.