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Northwest Clinical Genomics Lab >>
All NCGL Tests
Testing
Billing
Forms
Research Sequencing
NCGL Contact

Forms

Test Requisition Forms:

To complete electronically, select “Print Blank Form/Worksheet PDF” at top of form

Exome Test Requisition Form (Updated March 2021; includes Healthcare Provider Statement)

Exome Panel Test Requisition Form (Updated July 2021)

Billing Forms:

Request for Insurance Preauthorization Form

Medicare ABN (English)

Medicare ABN (Spanish)

Tricare (West) Form

Letters of Medical Necessity:

Sample Letter of Medical Necessity (genetic test)

DNA transfer and Medical Records Request Forms:

Request to transfer DNA from CPDx

CPDx Medical Records Release

LPDx Education and Training
LPDx Research
Our Story
Contact Laboratories

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