Genetic form 2025

1. Click ‘Get Form’ to open the Genetic Testing Recommendation Form in the editor.
2. Begin by filling out the Customer (patient) information section. Enter your name, Cigna customer ID, date of birth, and date of consultation accurately.
3. Next, provide the Ordering health care provider information. Include the provider's name, Taxpayer Identification Number (TIN), street address, telephone number, city, state ZIP code, fax number, and specialty.
4. If applicable, complete the Clinical geneticist or counselor information section with their details if different from the ordering provider.
5. Fill in the Rendering laboratory information by providing its name, TIN, address, telephone number, city, state ZIP code, and fax number.
6. List any relevant diagnosis codes in the designated area using ICD-10 format.
7. In the Requested test(s) information section, specify the requested test names and corresponding CPT/HCPCS codes. Indicate if it is a panel test.
8. Choose one recommendation option regarding testing criteria and provide any necessary explanations in the space provided.
9. Affirm your credentials by checking applicable boxes and ensure all required documentation is attached before signing and dating the form.

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