Forms

We have 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.

All Ambry Test Requisition Forms (TRFs) have been updated and improved. Please use the new versions available here and discard old ones. To ensure you are using the latest versions, please refresh your browser when viewing.

Our updated TRFs feature a new multi-gene panel ordering process for our hereditary cancer testing options. Please see PDF for all details on our new cancer ordering process.

Please note that our TRFs and Patient Consent Forms include a place for patients to consent to the use of their DNA sample for research purposes. Any data shared in the AmbryShare database belong to patients that previously consented to this.

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

  • *Effective immediately: we now only require 1 saliva collection tube for nearly all tests. Exceptions are below:
    - 2 saliva collection tubes are still required for: all pediatric testing and adults having ExomeNext for family member analysis
    - Saliva samples are still not accepted for: proband ExomeNext/ExomeNext-Rapid, CSTB dodecamer expansion analysis, PMEFirst, PMENext 

    We are currently updating our online and printed materials to reflect this update, so information here supercedes that found in our materials. 
    For more information about this update,
    please click here
     
  • Click here to view printable specimen requirements.

Client Satisfaction Survey

HIPAA AUTHORIZATON / ROI for Use/Disclosure Request for Protected Health Information

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.

UnitedHealthcare® Genetic Counseling Requirement

  • Effective January 1, 2016: UnitedHealthcare® will require genetic counseling from an independent genetics care provider before approving prior authorization requests for testing for BRCA1/2 mutations. You can read more in their bulletin and FAQs. As well, their current Prior Authorization Facsimile Request Form is here for BRCA1/2 testing requests.

    Please contact us at preverification@ambrygen.com with questions, concerns, or for more information.

Test Requisition Forms (TRFs) may be filled out electronically.  In order to take advantage of the TRFs enterable fields for saving repeated entries (i.e. GC name or Institutional Billing), save the form to your computer, then enter the fields of choice and save to your computer again.  Electronically completed TRFs will not be electronically delivered to Ambry, they must be printed and sent with the sample.  If you would prefer to submit your orders electronically, click here to get setup on using AmbryPort2 (AP2), our convenient online ordering and reporting portal.