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.

Ambry’s billing policy has been updated and will be effective October 1, 2015. This affects our materials with details about our previous billing policy, such as the “Billing FAQ” brochure and our previous “No Billing Surprises” brochure (in English and Spanish). Our new policy supersedes all current hard copy documents available and is now available in this new "No Billing Surprises” brochure. We have discontinued the "Billing FAQ" brochure. 

We still preverify insurance coverage (with or without patient sample) and contact the patient (after the sample is received) if their out-of-pocket cost is estimated to exceed $100. If you have any questions, our Billing Department can be reached by phone at 949-900-5795 or email at Billing@ambrygen.com.

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

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.