Non Invasive Prenatal Screening Page 3
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PRINT PATIENT NAME (LAST, FIRST, MIDDLE)
BILL TO:
Prenatal Screening
My Account
Insurance Provided
REGISTRATION # (IF APPLICABLE)
M
M
D
D
YEAR
SEX
Lab Card/Select
DATE
Patient
OF
BIRTH
PATIENT SOCIAL SECURITY #
OFFICE / PATIENT ID #
Reflex Tests Are Performed At
An Additional Charge.
-
-
ROOM #
LAB REFERENCE #
PATIENT PHONE #
PSC Appointment Website And
ACCOUNT #:
Telephone Number Information
(
)
NAME:
Listed On The Back.
PRINT NAME OF INSURED/RESPONSIBLE PARTY
(LAST, FIRST, MIDDLE) - IF OTHER THAN PATIENT
ADDRESS:
CITY, STATE, ZIP
Each Sample Should Be Labeled
With At Least Two Patient
PATIENT STREET ADDRESS (OR INSURED/RESPONSIBLE PARTY)
APT. #
KEY #
TELEPHONE #:
Identifiers At Time Of Collection.
DATE COLLECTED
TIME
TOTAL VOL/HRS.
Fasting
AM
:
STATE
ZIP
CITY
Non Fasting
PM
______ ML _______ HR
NPI/UPIN ORDERING/SUPERVISING PHYSICIAN AND/OR PAYORS (MUST BE INDICATED)
RELATIONSHIP TO INSURED:
SELF
SPOUSE
DEPENDENT
PRIMARY INSURANCE CO. NAME
GROUP #
MEMBER / INSURED ID NO. #
INSURANCE ADDRESS
STATE
ZIP
CITY
@
= May not be covered for the reported diagnosis.
Medicare
Provide
ADDIT’L PHYS.: Dr.
NPI/UPIN
F
= Has prescribed frequency rules for coverage.
Limited
signed
&
= A test or service performed with research/experimental kit.
Coverage
ABN when
NAME
I.D.#
NON-PHYSICIAN
B
= Has both diagnosis and frequency-related coverage limitations.
Tests
necessary
PROVIDER:
ICD Codes (enter all that apply)
Fax Results to: (
)
Client # OR NAME:
Send
Duplicate
ADDRESS:
Report to:
CITY:
STATE
ZIP
FOLD
FOLD
Aneuploidy Screening
Neural Tube Defect Screening
HERE
HERE
QNatal Advanced
TM
for fetal Chromosomal abnormalities (as early as 10.0 weeks gestation)
@5059
Maternal Serum AFP (MSAFP) (15.0 – 22.9 weeks gestation)
92777
Two 10mL Cell Free DNA Streck Tubes
1 mL Red Top SST
Collection Date:
______/______/______
Date of Birth: ____ /____ /_____ Collection Date: ____ /____ /____ Maternal Weight: _________ lbs
Estimated Date of Delivery (EDD): ____ /____ /____
Estimated Date of Delivery (EDD): ______/______/______
Determined by:
Ultrasound
Last Menstrual Period (LMP)
Physical Exam
Number of Fetuses:
One
Two
Three
More than 3
Mother’s Ethnic Origin:
African American
Asian
Caucasian
Hispanic
Other: _______
Maternal Height: _______ ft. _______ in.
Maternal Weight: _________ lbs
Number of Fetuses:
One
Two
More than 2
How many fetuses? ________
Increased risk due to (Must respond to all):
Yes No
Yes
No
Patient is an insulin-dependent diabetic prior to pregnancy
Advanced Maternal Age
This is a repeat specimen for this pregnancy
History of neural tube defect If yes, explain:
Abnormal MSS
Other Relevant Clinical Information:
Abnormal Ultrasound
Informed Consent for Maternal Serum AFP
Personal or Family Hx
1. Maternal Serum AFP (MSAFP) is offered to screen for open neural tube defects and may lead to
Other
the detection of 95% of fetuses with anencephaly and 65-80% of fetuses with open spina bifi da.
2. Neural tube defects (such as spina bifi da and anencephaly) occur when the spine and brain do
Opt-Out for subchromosomal copy variant (microdeletions)
not develop completely.
3. Some open neural tube defects and those covered with skin may not be detected. Most other
Opt-Out for fetal sex
birth defects and mental retardation are NOT detected by MSAFP screening.
Additional Comments
4. Screen positive results mean further testing may be necessary to determine if the fetus has a
neural tube defect. Such testing may include a repeat MSAFP test, ultrasound, or removal and
testing of a small amount of amniotic fl uid (amniocentesis).
5. Screen positive results may occur for reasons such as: miscalculation of due date, twin
pregnancy, vaginal bleeding, or the presence of other rare birth defects. Sometimes the results
are screen positive for no apparent reason.
6. At the request of your physician, screen positive results will be given to a diagnostic center for
follow-up.
I certify that I have read the above consent and understand its content, including the BENEFITS and
LIMITATIONS of Maternal Serum AFP Screening and request that it be performed. I have discussed
the test with my physician.
Patient Signature (required for New York residents only)
Date
Physician Signature (required for New York residents only)
Date
Call 866-GENE-INFO with
any questions
For any patient of any payor (including
Medicare and Medicaid) that has a medical
necessity requirement, you should only order
those tests which are medically necessary
for the diagnosis and treatment of the
patient.
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