Clinical Questionnaire for BRCAssureSM
This form should be completed by the ordering physician’s office (and signed by the patient) to select the processing option for BRCA1/2 testing (test numbers 252911, 252235, 252250, 252888, or 252970).
Please select the appropriate process and complete this form in its entirety. If you have questions best answered by a genetic counselor prior to
proceeding, please call 800-345-4363. If you have questions about this form, please contact BRCA Prior Authorization at 877-415-0002.
❍ Submitting completed questionnaire with sample
❍Prior authorization has already been completed.
❍ Submitting for prior authorization only, please include
Previous LabCorp specimen #:________________
Patient understands by signing below:
(form can be e-mailed to BRCAPriorAuth@LabCorp.com
or faxed to 855-711-5699, attention: BRCAssure prior authorization)
the patient’s address and a copy of their insurance card
(front and back)
The LabCorp prior authorization team will work with the patient’s insurance company to confirm medical necessity for BRCAssure testing. Please note that
authorization is for medical necessity only and is not a guarantee of payment. Eligibility is determined at the time the claim is received and benefits are subject
to the limitations and exclusions of the member’s plan.
• A prior authorization request to the patient’s health plan will be submitted.
• If the testing expense exceeds $300 (covered or not covered according to the patient’s health plan), testing will not proceed without patient permission.
The patient will be contacted at the number provided below to authorize further steps to perform the testing.
• If we are unable to reach you after three attempts, your test may be canceled.
Patient’s Signature (required) ______________________________________________________ Telephone _______________________________________
Patient/Physician Information
Patient’s name: ______________________________________________________
/
Date of birth: _____________________
Name and title of person completing form:____________________________________________________________
Physician’s name: ________________________________________________________________________________
Physician’s account #: ______________________
/
Physician’s phone #: ___________________________
/
/
Gender:
❍ Male ❍ Female
/ Date form completed:____________________
/ NPI:___________________________________
Physician’s fax #: ______________________________
❍
❍
Test #: 252911 | CPTs 81211; 81213 BRCAssure: Comprehensive BRCA1/2 Analysis
Required
Test #: 252970 | CPT 81212
ICD-9 or ICD-10 Diagnosis Code(s)
❍
Test #: 252235 | CPT 81215
❍
❍
Test #: 252250 | CPT 81217
Test #: 252888 | CPT 81213
BRCAssure: Ashkenazi Jewish Panel
BRCAssure: BRCA1 Targeted Analysis | Mutation:___________________________
(A previous report or proband sample must be provided to perform BRCA1 analysis)
BRCAssure: BRCA2 Targeted Analysis | Mutation:___________________________
(A previous report or proband sample must be provided to perform BRCA2 analysis)
BRCAssure: BRCA1/2 Deletion/Duplication Analysis
❍ Yes ❍ No
Was genetic counseling provided for BRCA1/2 testing? ❍ Yes ❍ No /
Does the patient have Ashkenazi Jewish ancestry?
If yes, genetic counselor’s name: ______________________________________________
Institution: _______________________________________________________________________________________
Has a quantitative risk assessment been provided for a BRCA1/2 mutation?
If yes, quantitative risk estimate:________________________________________
/
State: ___________________________
❍ Yes ❍ No
/
Risk model used?_______________________________________________
Patient Clinical Cancer History
❍ No personal history of cancer
❍ Ovary, age at Dx ___________
❍ History of bone marrow transplant
❍ Breast, invasive or DCIS, age at Dx ___________ (Check all that apply): ❑ Bilateral ❑ Premenopausal ❑ Triple negative (ER-,PR-,HER2-)
❍ Other cancer Type_________________________________, age at Dx ___________ / Type_________________________________, age at Dx ____________
❍ Negative BRCA1 testing ❍ Negative BRCA2 testing ❍ Negative deletion/duplication testing for BRCA1/2 ❍ Negative for Ashkenazi Jewish panel testing
Family History (Please attach pedigree or complete the table below.)
Available for Testing? Cancer Type
Relationship (Father, Sister, Aunt, etc) Maternal or Paternal Relative
If no, please state reason.
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Age At Diagnosis