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For Genetic Counselors
Update to Professional Interest Form
Clients without computer access may contact us by phone at 888-260-6543
Forms must be completed/ submitted prior to leaving our website
Please note that every item on this form requires an entry. Please type x or any letter, where you do not have an answer. Also, insurance information is not necessary for self pay or laboratory referred patients.
1. Today's Date (Month/Day/Year)
2. How can we help you?
3. First Name, M.I.:
4. Last Name
5. Date of Birth (Month/Day/Year)
6. Sex
Select
Male
Female
7. Client Status (single, married, other) necessary for insurance
Select
Single
Married
Other
8. Address
9. Day Phone (xxx-xxx-xxxx)
10. Evening Phone (xxx-xxx-xxxx)
11. Cell Phone (xxx-xxx-xxxx)
12. Cell phone number and carrier for text confirmation 48 h. before
( Ex: 111-111-1111. Verizon) Please type NO if you do not wish to receive a text confirmation 48 hours prior to your appointment.
13. Best Number to call for your Telephone Consultation
Please include area code. You will be called at this number at the time of your scheduled appointment unless you notify us otherwise in advance.
14. Email Address(es)
15. Please list here any restrictions concerning how and when to reach you
16. Primary Ins. Policy Holder's Name
If this is yourself, just type your name again.
17. Primary Ins. Policy Holder's D.O.B.
18. Primary Ins. Co. Name and Address (needed for testing auth.)
19. Primary Ins. Policy Holder's Employer / Address
20. Patient ID # / Group #
21. Secondary Insurance
Select
Yes
No
22. If yes, please fill out the following:
Secondary Ins. Policy Holder
Secondary Ins. Policy Holder's D.O.B.
23. Secondary Ins.Co. Name and Address
24. Secondary Ins. Policy Holder's Employer / Address
Secondary Ins. ID# / Group #
Patient Relationship to secondary Insured
Select
Self
Spouse
Child
Other
25. Primary Care Physician's Name and Address
26. Primary Care Physician's Phone #
27. Primary Care Physician's Fax #
28. Referring Physician's Name and Address
29. Referring Physician's Phone #
30. Referring Physician's Fax #
31. Consent for Genetic Counseling
I hereby request genetic counseling from a board certified genetic counselor through Genetic Counseling Services and Guide Genetics Inc. I understand that this service will comprise of taking an in depth personal and family medical history and analysis of potential risk for certain hereditary conditions and diseases. Based on the information that I provide, information about diagnostic or predispositional genetic testing for which I may be indicated will be offered for my physican and me to consider. I acknowledge that the genetic counselor does not diagnose, provide treatment, or order any type of test, that my physician is solely responsible for providing these services. By typing my name below, I acknowledge the above statements.
32. Signature of Minor here for consent of genetic counseling
Parent or Guardian must also sign above
33. Consent for Release or Request Information to/from Physicians and Insurance Company
I hereby authorize the staff of Genetic Counseling Services and Guide Geneticsto release and/or obtain medical information to/from referring physicians and my insurance carriers who are currently or potentially involved in my medical care. I understand that this information will be treated in a strictly confidential manner and will be used only for the purpose of securing medical and/or surgical treatments deemed necessary by my medical care providers and for payment of my care. I authorize my insurance provider to submit payments directly to Genetic Counseling Services for genetic counseling and I understand that I am ultimately responsible for my bill and any portion of it that is not covered by my insurance, unless otherwise discussed. By typing my name below, I acknowledge the above statements.
34. Minor signature here for consent to release information
Parent or Guardian must also sign above
35. Verifier
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