Request For Pre-Authorization For Cytogenetic Testing For Constitutional Samples
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1REQUEST FOR PRE-AUTHORIZATION FOR CYTOGENETIC TESTING FOR
CONSTITUTIONAL SAMPLES
To be completed and FAXED or CALLED to the insurance carrier.
PATIENT, INSURANCE, and REFERRING PHYSICIAN INFORMATION:
Patient Name:__________________________________
Date of Birth: __________________________________
Insurance Provider:______________________________
Phone:________________________________________
Policy ID #:____________________________________
Fax:__________________________________________
Policy Holder Name:_____________________________
Date of Birth:__________________________________
This patient is currently being cared for by the following physician, who recommends cytogenetic
testing on amniotic fluid/products of conception/solid tissue/peripheral blood specimen(s) be
performed by Diagnostic Cytogenetics Inc.
[Tax ID: 91-1134800 / NPI: 1104899376].
Referring Physician:_____________________________
Ref Phys’s NPI:__________________________________
Facility & Address:______________________________________________________________________________
City:_________________________________________
State:_________
Zip:__________________________
Phone:_______________________________________
Fax:___________________________________________
NECESSARY TEST(S) REQUESTED and CPT CODES:
Chromosome Analysis: amniotic fluid: 88235, 88267 or 88269, 88280, 88285, 88291
Chromosome Analysis: products of conception/solid tissue: 88233, 88262, 88280, 88291
Chromosome Analysis: peripheral blood: 88230, 88262, 88280, 88289, 88291
FISH: all tissue types: 88283, 88377
Some codes may be charged in multiple units, depending on patient-specific testing parameters.
Date of Service: _______________________________________________________________________________
Indication(s) for Testing:________________________________________________________________________
ICD-9 Code(s):_________________________________________________________________________________
How will approving this request change the course of treatment?
Goal of treatment?
What is the clinical justification for this request (if not addressed above)?
Submission of clinical chart notes is required to evaluate the medical necessity of request.
Making a diagnosis is essential for this patient’s current medical management and ongoing
healthcare.
Signed:_______________________________________________________________
Date:______________
Printed Name:______________________________________________________________________________
PLEASE FORWARD PRE-AUTHORIZATION TO:
Referring Physicians listed above
Diagnostic Cytogenetics Inc
Fax 206-325-2975 / Phone 800-328-2026
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