Application

Application for the Hereditary Breast and Ovarian Cancer Syndrome Genetic Testing Fund

This fund was made possible through the Georgia Breast Cancer License Tag Program. $22 of every Breast Cancer License Tag purchased goes to help underserved women in Georgia.
Please fill out the form completely. Incomplete forms will not be considered.

Decisions will be communicated within 5 business days. If approved, you will receive an identification number. The lab performing the testing will be chosen by Georgia CORE. You, as the Genetic Service Professional, will be responsible for education, ordering testing, securing test kits, and collecting and sending specimens. Following testing, Georgia CORE will request a de-identified copy of the patients results for tracking purposes. All invoices will be handled by Georgia CORE staff members. If you have any questions, please contact info@georgiacore.org.
Contact Information
Applicant must be a Genetic Service Professional as defined by Commission on Cancer Standard 2.3
Name *

First Name Last Name Credentials
E-mail *
Phone Number *

Area Code Phone Number
Name of Institution *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Requested BRCA testing option (Check One) *

BRCA 1+ 2 Deletion/Duplication 3 Founder Mutation Panel for Ashkenazi Jewish Single site for known mutation
Patient Information
Patient Initials *
Patients Age *
Patient Zip Code *
Race/Ethnicity *
Number of Dependents *
Income *
Insured? *

No Type
Choose All that Apply to the Patient *

Personal History of Breast and/or Ovarian Cancer Unaffected Contact attempt(s) to affected family member Diagnosed with cancer in last 6 months Testing results needed for surgical decision-making Suggestive family history Ashkenazi Jewish Ancestry Documentation of known deleterious mutation in family None of the Above
Additional Comments
Please Upload Patient's De-identified Pedigree *
Should be Empty:

Application for the Hereditary Breast and Ovarian Cancer Syndrome Genetic Testing Fund

Contact Information

Patient Information