Forms & Documents | Fulgent Genetics

Test Requisition Forms (TRF) & Consent Forms

Test Requisition Forms (TRF) - US

General Test Requisition Form

Beacon Carrier Screening Requisition Form

Chromosomal Sequencing Analysis (CSA) Requisition Form

Newborn Genetic Analysis (NGA) Requisition Form

Hereditary Cancer Comprehensive Test Requisition Form

Hereditary Cancer Focus Test Requisition Form

Pharmacogenomics (PGx) Test Requisition Form

COVID-19 Plus Influenza A&B Test Requisition Form

Consent Forms - US

Informed Consent for Genetic Testing

Informed Consent for Genetic Testing (Spanish)

Informed Consent for Beacon Carrier Screening

Informed Consent for Chromosomal Sequencing Analysis (CSA)

Informed Consent for Newborn Genetic Analysis (NGA)

Informed Consent for Prenatal Genetic Testing

Consent Forms - NY Approved Tests

Informed Consent for Genetic Testing - Fulgent Clinical Exome Sequencing

Test Requisition Forms (TRF) - EU/EEA

General Test Requisition Form - EU/EEA

Beacon Carrier Screening Requisition Form - EU/EEA

Chromosomal Sequencing Analysis (CSA) Requisition Form - EU/EEA

Consent Forms - EU/EEA

Informed Consent for Genetic Testing - EU/EEA

Informed Consent for Genetic Testing - EU/EEA (Spanish)

Informed Consent for Beacon Carrier Screening - EU/EEA

Informed Consent for Chromosomal Sequencing Analysis (CSA) - EU/EEA

Informed Consent for Newborn Genetic Analysis (NGA) - EU/EEA

Informed Consent for Prenatal Genetic Testing - EU/EEA

Family History Forms

Family History of Medical Concerns

Patient Family Resources

Family Follow-up Testing Letter

Carrier Screening Documents

Raw Request Forms

Raw Data Request Instructions

Insurance Forms

Insurance Forms

Aetna BRCA Precertification Request Form

Application For Economic Hardship

Benefits Investigation Request Form

Cigna Genetic Testing Recommendation Form

Financial Assistance Disclosure Form

UHC Genetic Counseling Attestation Form

Medicare Criteria

Advance Beneficiary Notice of Noncoverage (ABN)

Breast-Ovarian Cancer BRCA1-BRCA2 Medicare Criteria Form

Hereditary Colorectal Cancer Lynch Syndrome Medicare Criteria Form

Letters of Medical Necessity

Aicardi-Goutieres

Amyotrophic Lateral Sclerosis

Arrhythmogenic Right Ventricular Cardiomyopathy

Ataxia with Oculomotor Apraxia Type 1/2

Atrial Fibrillation

Basal Ganglia Calcification

Beacon Carrier Screening

Brugada Syndrome

Catecholaminergic Polymorphic Ventricular Tachycardia

Comprehensive Cancer

Congenital Sucrose Isomaltose Deficiency

Connective Tissue

Cornelia de Lange Syndrome

Dilated Cardiomyopathy

Early Onset Epilepsy

Essential Epilepsy

Holoprosencephaly

Idiopathic Epilepsy

Intellectual Disability

Joubert Syndrome

Joubert and Meckel

Marfan Syndrome, Thoracic Aortic Aneurysm & Dissection

Noonan Syndrome

Periodic Fever/Autoinflammatory Disorders

Polycystic Kidney Disease

Polycythemia Erythrocythemia

Skeletal Dysplasias

Questions?

Contact us at info@fulgentgenetics.com or +1 (626) 350-0537 for more information.