New Jersey Medicaid and NJ FamilyCare require this one-page form so a laboratory can be paid for a genetic or biomarker test. The ordering provider records the codes, the genes and test type, the clinical reason for testing, and how the result will change the patient's medical management. The laboratory submits it with its claim, but cannot fill it out itself.
The ordering provider completes and signs the whole form, with title and date. Forms completed by the laboratory are not accepted.
Download the current version from the source each time; forms change without notice.
Gene Assay/Biomarker Precision Medical Testing Information Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The form states it must be completed and signed by the ordering provider, and forms completed by the laboratory will not be accepted. The lab's role is to receive the signed form and submit it with its claim for the gene assay or biomarker test.
Provider and beneficiary details, the date ordered, CPT/HCPCS and ICD-10 codes, the gene or genes tested, the type of test, the reason for testing, and how the results will change or affect future medical management. The ordering provider then attests the test is medically indicated and necessary.