"*" indicates required fields
Appointment Information: Patient: ______________________________ Date: ________________________________ Time: ________________________________
Thank you for your interest in the Clinical Genetics Service. I look forward to working with you to evaluate your risk for breast cancer and/or hereditary cancers and to develop approaches to reduce your risks for cancer. Our service also includes risk assessment for those with breast cancer, ovarian cancer, colorectal cancer, uterine cancer, and other cancers to assess the role genetics may play in cancer development.
In an effort to expedite your visit, please complete the attached questionnaire packet and bring it to your appointment. In addition, if you or anyone in your family has already pursued hereditary cancer genetic testing, it is very important that you bring a copy of the test result to your appointment, if possible. If appointment not scheduled above, I will contact you to schedule an appointment convenient for you.
During your visit, we will review your personal and family history and your lifestyle questionnaire to assess whether a hereditarycancersyndromemayexplainsomeofthecancersinyourfamily. Wewilldiscussthebasicgeneticsofhereditary breast and ovarian cancer syndrome (HBOC), Lynch syndrome, and other cancer syndromes as appropriate and discuss strategies for an individualized healthcare plan for cancer risk reduction. If genetic testing is indicated, then testing can be initiated at the end of the appointment via a blood sample. Insurance coverage and the testing laboratory’s pre-authorization process will be discussed at your appointment.
Early Detection and Risk Reduction are our Key Goals in the Clinical Genetics Service.
If your insurance requires a referral from your primary care physician, then please ensure that a referral is completed prior to scheduling your appointment. All other charges will be filed with your insurance.
**If Imelda has emailed you a link to a family pedigree website, Volpara Health, then please complete the online questionnaire at least two days before your scheduled appointment. **
If you have any questions or need further assistance, please give me a call at 865-692-1602.I look forward to meeting with you soon.
Sincerely, Imelda G. Margulies, MSN, FNP- BC Director, Clinical Genetics Service Email: ImeldaFNP@AaronMD.com Fax: (865) 692-1619 Websites to View: www.aaronmd.com; www.mysupport360.com; www.ambrygen.com/patient
By signing below, I verify that all the information above is correct. I also verify that I have been offered and have reviewed a copy of the Patient Privacy Notice required by HIPAA and understand my right to privacy as a medical patient of Aaron G. Margulies MD, PLLC.
At the office of Aaron G. Margulies, MD, PLLC, we strive to give you the best possible care. In order to serve this purpose, it is important that our patients understand the process of reimbursement. Please read this Financial Responsibility Form and sign to acknowledge that you understand your accountability.
It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations, as well as, authorization requirements. This information can be obtained by contacting your insurance carrier.
We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of the visit, the financial responsibility for any payment due will be yours.
*If you have any changes in your insurance coverage you must notify us prior to your appointment.
The deductible is determined by your individual contract with your insurance carrier. You are responsible for your deductibles, copayments, and coinsurance. Your insurance company expects us to collect them from you at the time of service. Understand that you will be expected to pay deductibles, coinsurance and copayments, when this applies.
All patients are responsible for account balances if their insurance carrier denies payment for services rendered because they were stated as “non-covered services” or deemed as “medically unnecessary.” To avoid this, please check with your insurance carrier prior to receiving any treatment or services.
By signing below, I authorize the release of any medical information necessary to process insurance claims filed to my insurance carrier on my behalf or on the behalf of my dependents. I authorize payment for medical benefits to be made directly to my physician for services rendered at the office of Aaron G. Margulies, MD, PLLC.
I certify that I have read the above disclosure statements, understand my responsibilities, and agree to the terms written above.
Copyright © 2022 Dr. Aaron Margulies. All Rights Reserved. Website developed by Make Me Modern.