Date:
Requesting provider:
Contact Person:
Phone:
Fax:
Servicing Facility Information
Facility name:
Address:
TIN:
Contact Person:
Phone:
Member:
Member Id:
Fax:
Patient:
DOB:
Gender:	Male       Female
ICD Code(s):
CPT Code(s) Requested:
Collection Date:
Beginning Date of Service:
Ending Date of Service:
ANCESTRY:	Western/Northern Europe       Central/Eastern Europe              Africa       Near East/Middle East        Ashkenazi
	Latin American/Caribbean       Asia       Native American      Other

 

PATIENT PERSONAL HISTORY OF CANCER (Check all that apply)

NO PERSONAL HISTORY OF CANCER
BREAST, INVASIVE
Bilateral        Premenopausal       Triple Negative (ER-, PR-, HER2- pathology)
AGE AT Dx:
BREAST, DCIS
Bilateral        Premenopausal       Triple Negative (ER-, PR-, HER2- pathology)
AGE AT Dx:
OVARIAN / AGE AT Dx:
OTHER:	AGE AT Dx:

FAMILY HISTORY OF CANCER (Please indicate relationship, maternal or paternal, site of the cancer, and age at diagnosis. Indicate if bilateral, premenopausal, or triple negative breast cancer.)

NO KNOWN FAMILY HISTORY
RELATIONSHIP	MATERNAL	PATERNAL	CANCER SITE	AGE AT Dx
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NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.