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Use this form to request insurance authorization - UNMC

Use this form to request insurance authorization - UNMC 2026

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The document is a preauthorization information form from the Munroe-Meyer Institute for Genetics and Rehabilitation, detailing the process for requesting insurance authorization prior to genetic testing. It outlines necessary steps, including completing the attached form, providing patient insurance information, and submitting clinical records. The document emphasizes that this form is not an order for testing and provides contact details for further assistance.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Patient Information section. Include the patient's name, date of birth, biological sex, phone number, and address.
In the Testing to be Authorized section, select the appropriate tests that need authorization. Remember, this is not an order for testing.
Provide a clear copy of the front and back of the patient’s insurance card in the Insurance Information section. If applicable, include details about the policy holder.
Attach any necessary clinical records in the Clinical Information section. This may include family history and previous genetic testing reports.
Complete the Provider Information section with your details and specify how you would like to receive authorization updates (email or fax).
Finally, submit your completed form via email or fax using the provided contact information at the bottom of the form.

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