G001 FORM - Genetic Testing Authorization Form - 6 2019 Formatted docx-2026

1. Click ‘Get Form’ to open the G001 FORM in the editor.
2. Begin by entering the Patient Name, PreferredOne ID #, and DOB in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the ICD 10 DX and Procedure Code(s) as required. These codes are essential for processing your request.
4. Complete the Ordering Provider section by adding their Signature, First & Last Name, NPI #, Clinic Name, Address, City, State, Zip, Phone, and Fax.
5. In the Servicing Provider section (Lab), provide similar details including Name, NPI #, Address, City, State, Zip, Phone, and Fax.
6. List the Gene(s) being tested and the Disease/Sickness/Defect being tested for in the respective fields.
7. Check all applicable boxes under 'REQUESTS FOR GENETIC TESTING MUST MEET ONE OF THE FOLLOWING' to indicate eligibility criteria.
8. Detail how the test results will impact treatment or management by checking relevant boxes and providing explanations where necessary.
9. Review all entered information for accuracy before submitting. Once complete, save your document using our platform’s export feature.

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