Requests for laboratory developed tests, including genetic tests, go to Humana Military for TRICARE East review, and this one-page attestation collects the facts the request needs. The ordering provider identifies the performing laboratory and its CLIA status, the test names and codes, whether the patient was counseled about the test, and attests that the beneficiary meets the criteria in Humana's LDT chart.
The ordering provider completes and signs the whole form: patient and sponsor details, other health insurance, point of contact, ordering provider NPI, rendering laboratory details, test names, diagnosis codes and procedure or HCPCS codes.
Download the current version from the source each time; forms change without notice.
Laboratory Developed Test (LDT) attestation form
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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Log in to provider self-service at HumanaMilitary.com, submit the LDT request online, and attach this attestation completed in its entirety. Include the laboratory's NPI and CLIA number, the test names, diagnosis codes and procedure or HCPCS codes.
That the beneficiary meets the criteria listed in Humana Military's LDT chart, and that the information on the form is accurate and complete. The provider also states whether the beneficiary received counseling about the requested test, and signs and dates the form.
The form asks whether the rendering laboratory has CLIA accreditation or a certificate of compliance, with a yes or no answer and the CLIA number. The laboratory's name, address, NPI and phone number are also required.