XYZLABS

BRCA Pre-certification Information Request Form

Complete document and fax to the below address.

Patient Information

Physician Information

Independent Care Provider Information

Laboratory Information

Test (CPT) Information

Patient Cancer History

Patient Testing History

Family History of cancer/ethnicity

Relationship to Patient
Paternal/Maternal
Type of Cancer
Age of Diagnosis

Risk Criteria for Females

Risk Criteria for Males

Medical Management

SignOff Information

By signing off on this form, I certify that the patient listed above has given informed consent in accordance with the guidelines and risks outlined for BRCA analysis will be used to direct medical management of this patient.