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Department of Pediatrics, Division of Medical Genetics
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PEDIATRICS
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Your Genetics Appointment
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2008 Genetic/Birth Defects Clinic Schedule

To make your genetics appointment, you will be directed to either Mary Riske, Nurse Geneticist or Jayne Brown, Human Services Infomation Coordinator when you call (701) 777-4277.

You will be asked a variety of questions, some of which may include the following:

  • Patient's name, sex, date of birth
  • Patient's biological parent's names and/or adoptive parent's name
  • Legal guardian's name and address
  • If applicable, name of foster parents and their address
  • Addresses and phone numbers of those involved with the patient
  • We will ask the reason for referral and require the primary care physcian send our office a written referral for the patient's chart.
  • Referring physcian and their address
  • Name of insurance
  • We will be requesting records from medical providers, such as clinics, hospitals, doctors and specialists
  • We will be requesting (if applicable) school records such as IQ testing, developmental Evaluations, IEP's/504's and infant development
  • If you are being seen for genetic counseling regarding pregnancy, we will need both partner's family history completed and returned to our office.

The required forms needed for your appointment are listed below and are available for you to download clicking on them. Please return them as quickly as possible to our office, or as directed by either Mary or Jayne.

Word Document PDF Document Spanish Document (Word)
Release of Information Form

Solicite Para la Liberación de Información

 
 
Billing Form
 
 
     
Prenatal Development of Patient who is a child  
     
Birth History of Patient Seen Birth History of Patient Seen  
     
Other Forms
For Families With Children Who Have Special Needs
North Dakota 's Children with Disabilities Coverage program North Dakota for families to access the Medicaid program as a critical supplemental insurance

ND Dept of Human Services
Application for Health Care Coverage for Children, Families & Pregnant Women

 
Medicaid coverage along with economic assistance programs
Application for Assitance (SFN 405)
 
 

To obtain our recent brochure, describing North Dakota's Genetic/Birth Defects Evaluation and Counseling Service, click HERE.

 

 

Dept. of Pediatrics
UND School of Medicine & Health Sciences Room 5910
501 N. Columbia Rd.Stop 9037
Grand Forks, ND 58202-9037
Telephone: 701-777-4277
Fax: 701-777-3220
Email: jbrown@medicine.nodak.edu

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