• GENETICS CENTER

    GENETICS CENTER

    INSURANCE AND PAYMENT INFORMATION
  • PATIENT INFORMATION

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  • SPOUSE/PARTNER INFORMATION

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  • INSURANCE INFORMATION

  • Your signature below confirms that the information submitted above is true and correct to your knowledge and that you have read, understood, and accept our Insurance, Payment, and Other Terms on a separate page.

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  • Copyright c GENETICS CENTER. All rights reserved.

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  • GENETIC SCREENING QUESTIONNAIRE

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  • Family and Patient History

  • 1. Is your family or your partner's family...

  • 2. Have you, your partner, or anyone in either of your families ever had any of the following disorders?

  • Pregnancy History

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  • 4. During this pregnancy, have you had any of the following? (If "yes", please describe, including dates, if known): 

  • My signature below indicates that the above family and pregnancy history information provided is complete and correct.

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  • Recommended Prenatal Genetic Screening Tests

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  • The following tests are recommended to be offered to every patient who is planning a pregnancy or who is already pregnant. The testing can determine if the pregnancy is at a higher risk than the general population of having these conditions. Currently, there is not a cure for these conditions prior to or after birth. If the risk of these conditions is higher, you would be offered further diagnostic testing. The purpose of having this information about your developing baby is so that you can prepare yourself to care for a child with special health care needs or choose to not continue an affected pregnancy. Please review the basic information regarding these conditions. If you would like more information or have further questions, your genetic counselor can answer them for you. We can also verify insurance coverage for this testing.

     

  • Cystic Fibrosis

    • CF is a life long illness that causes problems with digestion and breathing. CF
    does not affect intelligence or appearance. In California, all infants are tested for
    this condition at birth through the State Newborn Screening Program.

    • CF is most common in individuals of European, Caucasian, or Jewish descent.
    However, CF has been reported in other populations as well.

    • To have a child with CF, both parents must carry a genetic change or mutation.

    • CF carrier screening does not detect all CF carriers. The detection rate varies by
    specific ethnic group.

     

  • Spinal Muscular Atrophy (SMA)

    • SMA is a serious condition that causes progressive muscle weakness and
    paralysis. Children with SMA type 1 usually die from respiratory failure by 2 years
    of age. Other types of SMA are less severe, but are also disabling.

    • SMA affects all ethnic groups equally. The chance of being a carrier is
    approximately 1/50 in the general population.


    • To have a child with SMA, both parents must carry a genetic change or mutation

    • SMA carrier screening does not detect all SMA carriers. 6-9% of carriers of SMA
    are not detected by current technology.

    • The severity of SMA cannot be predicted by genetic testing.

     

  • Fragile X syndrome

    • This condition is the most common cause of inherited mental retardation and
    developmental delay in males. Behavioral abnormalities, including autism
    spectrum disorder, are also common.

    • Only females can carry the genetic mutation that causes Fragile X syndrome.
    Males with Fragile X syndrome are more severely affected than females with this
    condition.


    • The incidence in the general population is approximately 1/2000 to 1/4000 live
    births

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  • *I acknowledge that the values and limitations of DNA testing have been explained to me, and I give my consent for testing.

  • FOR COUNSELOR USE ONLY

  • I have received and understand the information on Spinal Muscular Atrophy & Fragile X syndrome

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  • REQUEST FOR MEDICAL INFORMATION BY GENETICS CENTER

  • 211 SOUTH MAIN STREET, SUITE E, ORANGE, CALIFORNIA 92868

    TEL. 714.288.3500   FAX 714.288.3510

    GENETICS CENTER is currently treating the patient identified below, and we are requesting that medical information for that patient be released to GENETICS CENTER and forwarded to us at the above address.

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  • Information Requested: Screening Results from The California Prenatal Screening Program

  • I hereby authorize release of the above records to GENETICS CENTER.

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  • FOR OFFICE USE ONLY

  • Medical Information being requested from:

    Physician or Facility: California Department of Public Health - Genetic Disease Screening Program.

  • Please return a copy of this form with the records. Thank you.

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  • GENETICS CENTER

  • Notice of Separate Fee From the California Prenatal Screening Program.

    The California Prenatal Screening Program has a separate fee of $221.60 for enrollment in their program. This single program fee covers both the first and/or second blood test and any authorized follow up services (this does not cover the nuchal translucency ultrasound Please see page 18 of the blue California Prenatal Screening Program booklet for further

    For any questions regarding this $221.60 fee, please directly call the State at 510-412-1613, as Genetics Center is not involved in this billing.

    I acknowledge that I have read this form and am aware of the separate State fee:

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  • The State is out-of-network with all insurance companies and you may receive a separate bill from the State. If so, fill out their insurance form and return it along with the bill directly to the State.

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  • Insurance, Payment and Other Terms

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  • AUTHORIZATION TO RELEASE INFORMATION FOR BILLING

    I authorize the Genetics Center and its medical affiliates to release any information acquired in the course of my examination and treatment to my insurance company for billing purposes.

    AUTHORIZATION TO RELEASE PAYMENT(S) TO GENETICS CENTER

    I irrevocably assign and transfer insurance payment(s) directly to the Genetics Center.

    INSURANCE ELIGIBILITY

    I certify that I am eligible with my insurance company. I understand that if this is not true or if I am not eligible for some or all of the Genetics Center services under the terms of my insurance contract, I am liable for any and all charges for services rendered. Also, if I am not eligible, I agree to pay in full for all services rendered
    within thirty days of receiving a bill from the Genetics Center.

    INSURANCE AND PAYMENT TERMS

    I acknowledge that all medical bills are due and payable at the time services are rendered. However, as a courtesy to me the patient, Genetics Center will submit my claim to my insurance company for me. I understand that my insurance coverage is a contract between me and my insurance carrier. If it is my desire to
    have Genetics Center bill my insurance carrier for these services, I will present my insurance card.


    I also acknowledge that all co-pays and unmet deductibles are due and must be paid at the time of service. In certain cases, Genetics Center may also require some deposit in advance. If my insurance company pays more than was collected, Genetics Center will promptly reimburse me that amount of the deposit. In some cases, my insurance will only cover a portion of the fees. If I have made an initial payment, it will then be applied to my balance. If Genetics Center does not receive payment from my insurance carrier within 60 days from the date of my service, Genetics Center may look to me for payment in full. A monthly 1.5% service charge will be added to balances over 30 days old, and a $10
    statement fee will be added to balances over 60 days old. The charges for Genetics Center services are ultimately my responsibility.

    BENEFITS AND COVERAGE CHECK IS SUBJECT TO CHANGE

    Genetics Center cannot accept responsibility for any differences between what was quoted to them by my insurance during their courtesy benefits and coverage check (copay, deductible, etc), and the final benefit determination performed by my insurance when my claim is processed. Therefore, I may owe a different amount than what was quoted to me prior to services.

    ACKNOWLEDGMENT OF INDEPENDENT CONTRACTORS

    I acknowledge that some providers involved here are not employees, but are independent contractors, specifically including the NT practitioners, sonographers, and perinatologists.

    ACKNOWLEDGEMENT OF POTENTIAL BILLING BY OTHER PROVIDERS

    I acknowledge that there could be other providers involved, such as ultrasound, hospital, perinatologist, etc., which will have their own billing.

    AUTHORIZATION TO RECEIVE VOICE MESSAGES

    I authorize the doctor and/or facility and/or staff to identify themselves as being from Genetics Center when calling to leave a message regarding my appointment, results, or other medical information on any answering device or with another person answering the phone.

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge that I was offered a copy of the Genetics Center's Notice of Privacy Practices.

     

    My signature confirms that I have read, understand, and accept these terms.

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  • Copyright GENETICS CENTER. All rights reserved

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