Healthcare Patient Genesight Form

Healthcare Patient Genesight Form

Patient Information

Patient Name:

Female Male Other:

Insurance and Billing

I authorize the ordering clinician and laboratory to bill my insurance for genetic testing and related services. If insurance does not cover testing, I accept financial responsibility:

Ordering Clinician / Facility

Clinical Information & Medication History

Indication for Genesight testing (diagnosis, medication problems, or clinical question):

Current medications (include dose and frequency):

Known medication allergies or adverse reactions:

Specimen Collection

Preferred specimen type: Saliva Cheek (buccal) swab Other:

Date specimen collected:

Consent for Pharmacogenomic Testing

I authorize the laboratory to perform pharmacogenomic testing (Genesight) on my specimen to analyze genes relevant to medication response. I understand results identify genetic variants that may affect medication efficacy, metabolism, or risk of adverse effects. I acknowledge that:

1. Testing is voluntary and intended to assist clinical decision-making; it does not guarantee medication response.
2. Results will be documented in my medical record and disclosed to the ordering clinician and treating providers to inform care.
3. The laboratory will retain the specimen and results as required by law and laboratory policy; specimens will not be used for unrelated research or commercial purposes without separate authorization.
4. I may decline testing or withdraw this authorization at any time by notifying the ordering clinician in writing; withdrawal will not affect actions already taken based on this authorization.

I have had the opportunity to ask questions about the test, its nature, potential benefits, and limitations. I understand that genetic information may have implications for family members, and that protections against genetic discrimination exist under federal law, including the Genetic Information Non-Discrimination Act (GINA), which limits certain uses of genetic information by health insurers and employers.

HIPAA Authorization to Use and Disclose Protected Health Information

I authorize disclosure of my protected health information, including genetic and pharmacogenomic test results, demographic and clinical information, and specimen information, to the ordering clinician, treating providers, my insurance payers for claims adjudication, and the laboratory performing the test. This authorization includes disclosure by the laboratory to its subcontractors for reporting and quality assurance purposes.

To inform treatment decisions, coordinate care, and permit billing and payment for services.

I understand that I may revoke this authorization at any time by submitting a written revocation to the ordering clinician. Revocation will not apply to disclosures made prior to receipt of the revocation. My refusal to sign this authorization will not affect my ability to obtain treatment, except when the refusal prevents the clinician or laboratory from providing services requiring the authorization.

Release of Results and Permissions

I authorize the laboratory to release test results and interpretive reports to the following individuals or entities (names and relationship or role):

I authorize the laboratory to store de-identified data for internal quality improvement. I consent to this use: Yes

Acknowledgment and Certification

By signing below I certify that I have read and understand the information provided in this form, that the information I provided is true to the best of my knowledge, and that I consent to the collection, testing, and disclosure as described. I understand the potential benefits and limitations of pharmacogenomic testing and the privacy protections and limits described above.

If signed by a personal representative, I certify that I am the personal representative of the patient and have authority to execute this authorization on the patient's behalf under applicable law.

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