Forms

Forms

HGL provides customized request forms for oncology, postnatal, prenatal, & male infertility diagnosis.  Utilizing the appropriate form in addition to providing accurate and complete information (including an enlarged photocopy of the patient’s insurance card and prior authorization if needed) will avoid delay in specimen processing.

ONCOLOGY:  bone marrow, cancer blood, lymph node, solid tumor, paraffin embedded tissue, urine, & other (body fluid)

• Oncology Test Request Form
• HER2/neu Test Request Form

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POSTNATAL: blood & skin

• Postnatal Test Request Form

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PRENATAL DIAGNOSTIC: amniotic fluid, chorionic villi (CVS), & fetal tissue

• Prenatal Test Request Form
• Pregnancy Loss Test Request Form

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PRENATAL SCREENING: maternal serum

• Quad Fetal Risk Screen and 
  Maternal Serum Alpha-Fetoprotein ONLY (MSAFP) Request Form

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MALE INFERTILITY: blood

• Male Infertility Test Request Form 

FISH RESEARCH Test Request Form

FINANCIAL FORMS

• Request for Pre-Authorization for Genetic Testing (Hematology/Oncology)
• Request for Pre-Authorization for Genetic Testing (Prenatal Diagnoses)
• Request for Pre-Authorization for Genetic Testing (for Pregnancy Loss)
• Advanced Beneficiary Notice of Noncoverage (ABN)
• Advanced Beneficiary Notice of Noncoverage (ABN) - Spanish version
• Self-Pay Waiver of Services 

Adobe Acrobat Reader is necessary to view/print all forms.

revised 3-19-2013