Customer Service Forms

Advanced Beneficiary Notice of Non-coverage (ABN) - This is a Medicare-specific form for patients who do not meet Medicare criteria or for testing when no Medicare criteria exist.
Aetna Authorization Form – This document is needed for Aetna patients when a BRACAnalysis® test is ordered.
Ancestry Chart - This chart can be used to help fill out the ancestry section on the Test Request Form.
Ancestry and Clinical History Form – This form is used to update, clarify or add additional clinical history for a patient.
Authorization to Use and Disclose Protected Health Information (En Español) - This form may be used to request test results of previously tested family members and allow patients to authorize the release of test results to healthcare providers other than the ordering provider.
Confirmation of Test Request Form – This document is used by the ordering physician to modify or add additional testing for a patient.
Medicare Informed Consent Form – A copy of this document is required for Medicare patients who meet Medicare criteria or as a substitute for the Informed Consent documentation requirement on the test request form. En Español
Medicaid Waver - Patients with Medicaid who do not have coverage for testing but would like to proceed with testing must complete this form.
Myriad Financial Assistance Program - If a patient encounters ANY financial hardship associated with their bill, Myriad will work directly with the patient toward their complete satisfaction, GUARANTEED.
Non-covered Services Consent Form - Patients who do not have coverage for testing through their insurance but would like to proceed with testing must complete this form when their insurance requires written documentation from the patient that they would like to proceed with testing despite no coverage through their insurance.
Pedigree Template — this form can be used to assist healthcare providers in completing a 3 generational pedigree.
Return Sample Request Form – This document allows Myriad to send remaining DNA to another facility or DNA banking facility. Please note that in addition to this form, a $50.00 fee is required.
Sample Destruction Request Form – This document is for patients who do not want Myriad to retain their DNA for the usual 60 day time period after test release or cancellation.
Substitute Insurance Billing Information/Signature Form – This form can be used if the patient’s signature is missing on the original Test Request Form. This form is also used to confirm insurance policy information.  En Español.
TriCare-Beneficiary-Liability-Form (Waiver-of-Non-Covered-Services) -This waiver allows a network (contracted) provider to collect billed charges for services denied as ‘non-covered’ (not a TRICARE benefit) from a TRICARE beneficiary when the beneficiary has agreed, in writing, to waive his or her balance-billing protection.

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