ExecutiveCheckUp_Dec4_Men_EnglishVersion 2

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HEREDITARY CANCER Testing
Requisition
City State Zip
Physician
Name
Address
Phone DOB Gender City State Zip Phone
Ancestry
Email
D Caucasian
D Western European
D African American
D Caribbean
D Ashkenazi Jewish
D Eastern European
D Native American
D Asian
D Central/South American
D Hispanic
D Northern European
0 Middle Eastern
D Pacific Islander
D Other:
D Male D Female
Fax
Paben! has had a blood transfusion B s
1- ------------------------------------1 2-4 weeks of wan bme is required for some testing.
PLEASE PROVIDE LIST OF CURRENT MEDICATIONS
Name of
Policyholder
4. BILLING INFORMATION
Email
If "Yes" - Date of the last transfusion:
Specimens are not accepted for patients who have had allogeneic bone marrow transplants.
BILL: D Insurance D HSA D Medicaid D Medicare D Se Pay D Worl<er's Compensation
DOB: Medicare# Medicaid#
Relabonship to Policyholder
□ Se □ Spouse □ Dependant □ Other _____________________ _
Insurance
Company
Worker's Comp
Date
Claim# of Injury j'
Policy #
Group#
0 NO PERSONAL HISTORY O Ovarian Cancer, Age at Ox _ _ _
0 NO KNOWN CANCER AT THE PRESENT TIME O I AM CURRENTLY DIAGNOSED WITH CANCER
D Bladder, Age at Ox
D Melanoma, Age at Ox ___ _
□ Breast Cancer, Age at Ox
D Pancreabc Cancer, Age at Ox _ _ _
Please describe what type(s) of cancer
Date of Ox
□ Bilateral D Premenopausal □ Prostate Cancer, Age at Ox _ _ _
D Triple Negative (ER-, PR-, HER2-)
Gleason Score ___ _
□ Colorectal cancer, Age at ox
Testicular Cancer, Age at Ox _ _ _
D Gastric Cancer, Age at Ox □ Uterine/Endometrial Cancer, Age at Ox _ _
□ Kidney (Renal), Age at Ox D Colon Polyps (How Many_), Age at Ox _ _
D Other Cancer Type(s) ________________ Age at Ox. ___ _
6. FAMILY HISTORY OF CANCER 8. HEREDITARY CANCER TEST SELECTION
0 NO KNOWN FAMILY HISTORY OF CANCER
D Known familial mutation: Gene
Relationship
Gene
D Adopted (history unknown)
Mutation
Mutation
Maternal Paternal Cancer Site Age at Ox
ICD-10 DIAGNOSIS CODES: _ _ _
□ HEREDITARY CANCER COMPREHENSIVE PANEL - 108 GENES
ABCB1 ;ACTRT3;AIMP2;AKT1 ;ALK;APC;AR;ARHGAP44;ATF1 ;ATM;AXIN2;BAG6;BMPR1A;
BRAF;BRCA1;BRCA2,BRIP1;BUB1B;CASC17;CASC8;CCHCR1;CDH1;CDK10;CDKN1A;
CDKN2A;CHEK2;CHRNA3;CLPTM1L;COLCA1;CTD-2194D22.4;DBNDD1;DICER1;EGFR;
EHBP1;ELAC2;EPCAM;ETS2;FGF10;FGFR4;FH;FLACC1;FLCN;HNF1B;HPDL;HYKK;IRF1;
ITGA6;KLK3;KRAS;LAMA5;LMTK2;MAP2K7;MAP4K2;MAX;MEN1;MIR5580;MITF;MLH1;
MLH3;MLPH;MSH2;MSH6;MSMB;MSR1;MTAP;MT-ND3;MUTYH;MXl1;NF1;NUDT11;PADl6;
PALB2;PCAT2;PDLIM5;PIGU;PMS2;POU5F1B;PTEN;RAD51;RAD54B;RAD54L;RB1;RET;
RFX6;RHPN2;RNA5SP299;RNASEL;RNU1-19P;RRAS2;RUNX1;SDHB;SDHC;SDHD;
SLC22A3;SMAD4;SMAD7;STK11 ;TERT;THADA;TMEM127;TP53;TP63;TSC1 ;TUBB3;VHL;
WEE1 ;XRCC1 ;XXYLT1
9. PATIENT CONSENT 10. MEDICAL NECESSITY FOR TESTING
Billing ABN and Patient Plan Information: A completed Advance Beneficiary Notice (ABN) of coverage
is required for Medicare patients who do not meet medical criteria for testing. This does not apply to specific
site analyses. Insurance pre-qualification will not be performed for these tests, unless specifically requested.
All tests ordered shall be processed and billed based on payor.
Patient Acknowledgment: I am covered by insurance and authorize Novomed Specialized Clinics to
give my designated insurance carrier(s) plan on this form and other informabon provided by my health care
provider necessary for reimbursement. I authorize Novomed Specialized Clinics to inform my Plan of my
test results only if test results are required for preauthorizabon of or payment for reflex/additional testing.
I authorize Plan benefits to be payable to Novomed Specialized Clinics. I further authorize payment of
benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any
responsibility concerning payment for laboratory services and that I am financially responsible for all
charges whether or not they are covered by my insurance. I understand that any payment I receive for
services rendered by the laboratory from my insurance provider should be forwarded immediately to the
laboratory.
The data may also reveal secondary or incidental findings, such as that you may be at risk for certain
genebc diseases or that you are a carrier of disease associated mutations.
Patient Consent: My signature below consrnutes my acknowledgment that the benefits, risks, and
limnations of this testing have been explained to my satisfaction by a qualified health professional and
I have received a copy of the full informed consent document. I have been given the opportunity to ask
questions before I sign, and I have been told that I can ask questions at any other time. I voluntarily
agree to genetic testing.
Patient Consent for Research: □ By checking this box I DO NOT consent for the remaining part
of my sample to be used for research purposes by Novomed Specialized Clinics.
Personal information will not be shared and will be kept confidenbal by Novomed Specialized Clinics.
If Signature is other than patent's. Printed Name ________________ _
This test is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndrome
or disorder, and these results will be used in the medical management and treatment for this patient.
Furthermore, recipients' information is true and correct to the best of my knowledge.
The person listed as the Ordering Physician or genebc counselor is authorized by law to order the test(s)
requested herein. I confirm that I have provided genetic tesbng informabon to the patient and they have
consented to genetic testing.
Please check all that apply:
□ I confirm that the above patient's gene testing is medically necessary and the result will be used
to assess pabent for Mure cancer risk.
□ I agree to allow Novomed Specialized Clinics to transfer the information contained in this requisition
to an LMN (Letter of Medical Necessity) using the ordering physician's name as his/her signature
for insurance billing purposes.
D I have attached a LMN for insurance billing purposes.
D Patient meets clinical/genetic tesbng criteria for the above ordered tests.
HEALTH CARE PROVIDER'S SIGNATURE
TEST SUBMISSION CHECKLIST
D Copy of Patient Demographics Collected by: i:
D Current Meds List
D ICD-10 Diagnosis Codes
Print Name
D Patient's/Provider's Signatures
i1_
D Copy of Insurance Card (Front/Back)
a:
PATIENT'S OR RESPONSIBLE PARTY'S SIGNATURE DATE O Attach Patient's HG Insurance Pre-Authorizaton Form Sgnature c'j
,__________________________________ _.__________________________________ _,I
Novomed Specialized Clinics • Suite 3002 - 3005 30th Floor, Marina Plaza, Dubai Marina, Dubai, UAE • Phone : 971 4 247 3100
Tests are performed in USA, results in one week.
DATE