Forms

Ambry Genetics has a rapidly-expanding list of resources that can be very helpful when preparing for genetic testing. Below we have listed consent, letters of medical necessity and several other forms that will assist you in preparing for, processing and completing your genetic testing.

*NEW BAR CODE LABELS (March 2015) – All TRFs now contain a new section for applying a bar code sticker to the bottom of the front page.  Matching bar code stickers will be available in all kits that are sent out from the Ambry Genetics kit department.  Instructions are to affix blue colored bar code label to TRF. Affix matching numbered red colored bar code label to specimen. Please do not apply barcode sticker to small DNA vials.

Test Requisition & Preverification Forms

Letters of Medical Necessity

Family History Forms

Advance Beneficiary Notice Of Noncoverage (ABN)

Consent

State of New York Forms

Sample Submission Requirements

Client Satisfaction Survey

Aetna Prior Authorization Form for BRCA1/2 Testing

  • Aetna Prior Authorization Form for BRCA1/2 Testing

    NOTE: This form is only required for Aetna patients, for any test that includes the BRCA1 and/or BRCA2 genes.  This form can be faxed beforehand to (949) 900-5501, or submitted along with the lab requisition and specimen. Once received, Ambry will complete the preauthorization process on the patient's behalf.