3545 N.W. 58th St., Ste. 600, Oklahoma City, OK 73112
Phone: 405-717-8879 or 800-543-6044, ext. 8879
Fax: 1-405-949-5459 or 1-405-949-5501

BRCA REQUEST

This form must be completed and accompany all requests. Incomplete forms will not be reviewed.


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Male       Female
 
 
 
 
 
 
   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
 
 


** All information is required for review. Information provided is private and confidential. **

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.