Healthcare DNA Banking Form

HEALTHCARE DNA BANKING FORM

This DNA Banking Form documents the voluntary placement of a biological specimen and associated genetic material into long-term storage for future clinical testing, research, or authorized release. The patient authorizes collection, processing, storage, and release as described below and acknowledges the risks, limitations, and rights set forth in this document.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information (if applicable)

Medical History

Specimen and Banking Instructions

Type of specimen to be banked (check all that apply):

Blood    Saliva    Tissue    Buccal swab

Intended uses (check all applicable):

Clinical testing for patient care    Research (de-identified unless otherwise specified)    Future genetic testing or re-analysis   

Indefinite until revoked    Store for years

Authorization to Release and Use Genetic Material

I, the undersigned, authorize the collection, processing, extraction of DNA, and long-term storage of the specimen identified above. I authorize the laboratory and its authorized agents to: (1) perform genetic analyses necessary for the intended uses checked above; (2) retain extracted DNA and derived data; and (3) release my stored specimen or genetic information to persons or entities designated below, subject to the limits set forth in this document.

I understand that release of identifiable genetic information to third parties may occur only with my written authorization, except as required by law. I authorize release to the designated recipient above for the stated purpose only.

Privacy, Confidentiality, and HIPAA Acknowledgment

The patient authorizes use and disclosure of protected health information and genetic test results as necessary for storage, analysis, billing, and authorized release. The facility will employ reasonable safeguards to protect confidentiality but cannot guarantee absolute privacy. Genetic data used for research will be de-identified unless separate authorization is provided.

I acknowledge receipt of the privacy practices and understand how my genetic and health information may be used and disclosed for the purposes described above.

I acknowledge and consent to the privacy and use provisions above

Withdrawal, Disposal, and Transfer on Death

I understand I may revoke this authorization in writing at any time, provided revocation will not apply to actions already taken in reliance on this authorization. Upon written request, the facility will, when feasible, destroy or return the remaining specimen and/or DNA. In the event of my death, I direct that the specimen be: Retained for my heirs' use    Destroyed

Fees and Billing Authorization

I agree to be responsible for fees associated with collection, processing, and storage unless otherwise arranged in writing. The facility may bill the patient or the insurance subscriber for services rendered.

Risks, Limitations, and Certifications

I understand that genetic testing and storage may reveal information about disease risk, carrier status, or ancestry. Results may have implications for employment, insurance, or family members. There is no guarantee that a specimen or stored DNA will remain viable indefinitely. The laboratory and affiliated providers are not responsible for third-party misuse of disclosed information beyond the limits of this authorization.

I certify that I have read and fully understand this form, that my questions have been answered, and that I consent voluntarily to the collection, processing, storage, and authorized release of my specimen and genetic information as described.

If no date is specified above, this authorization will remain in effect until revoked in writing or until specimen destruction as directed.

Patient Certification and Signature

By signing below, I certify that I am the patient or the patient's legal guardian, that I have the authority to execute this authorization, and that I accept the terms and conditions set forth in this Healthcare DNA Banking Form.

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