Healthcare Genetic Testing Form

Healthcare Genetic Testing Form

Purpose: This form documents patient authorization for genetic testing, specimen collection, testing and reporting, release of protected health information necessary for testing and billing, and preferences for return of results. Genetic testing may reveal information about inherited conditions, carrier status, pharmacogenomic variants, and incidental findings. Testing results may have implications for biological relatives and for future medical and reproductive decision-making.

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Ordering Provider / Facility

Insurance & Billing

Specimen & Test Selection

Specimen Type (select all that apply): Blood Saliva Buccal swab Tissue Other

Test Requested: Single gene analysis Gene panel Whole exome sequencing Whole genome sequencing

Risks, Limitations, and Benefits

I understand that genetic testing may not identify a cause for my condition. Results may be uncertain (variants of uncertain significance), and may require follow-up testing, segregation studies, or specialist interpretation. There may be psychological, familial, insurance, or reproductive implications. Testing may reveal non-paternity or other unexpected relationships. There is no guarantee that testing will provide a definitive diagnosis.

I acknowledge that the risks and limitations described above have been explained to me.

Genetic Counseling

I have been offered genetic counseling to discuss the scope of testing, possible outcomes, and implications for myself and my family. I understand that a genetic counselor or ordering provider is available to review results and next steps.

I was offered genetic counseling. I decline genetic counseling at this time.

Authorization for Testing, Storage, and Use

By checking the boxes below I authorize the laboratory to perform the requested genetic test on the specimen provided, to release test results to the ordering provider and other designated persons, and to use my de-identified data for quality assurance. I understand that identifiable specimens may be retained for a period necessary for test verification and quality control unless otherwise rescinded.

I authorize genetic testing as described above.

I authorize the laboratory to retain my specimen and extracted DNA for internal quality assurance and future confirmatory testing.

I authorize de-identified use of my genetic and clinical data for research and assay development (no direct identifiers will be provided).

Release of Results and Privacy

I authorize release of test results and related protected health information to the ordering provider and the following person(s) as indicated. I understand that genetic information is part of my protected health information and will be treated in accordance with privacy laws and the laboratory's privacy policies.

Result Delivery Preferences: Send results to patient Send results to ordering provider Release results to family member listed above

Limitations on Use and Disclosure

The laboratory will use reasonable safeguards to protect confidentiality. However, genetic results may be subject to disclosure under law, or to third-party payors for purposes of payment. I authorize release of information to insurers for billing, and understand that insurance may require submission of clinical information relevant to medical necessity.

I authorize the laboratory to bill my insurance and release necessary information to process claims.

Medical / Family History

Consent, Certification, and Acknowledgement

By signing below I certify that I am the patient named above or the patient's legally authorized representative. I have read and understand the information provided in this form, including the risks, limitations, and the authorization for testing, storage and disclosure. I authorize the collection and testing of the specimen and the release of results as indicated above.

I understand I may withdraw this authorization at any time by providing written notice to the ordering provider and the laboratory, except to the extent that action has already been taken in reliance on this authorization. This authorization is voluntary and will expire on the date specified above, or otherwise as required by law.

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