Medical Genetics Consent Form

MEDICAL GENETICS CONSENT FORM

WHEREAS

WHEREAS Patient Name: (hereinafter referred to as "Patient") seeks genetic testing and related services; and

WHEREAS Provider Name: (hereinafter referred to as "Provider") is duly qualified and equipped to perform genetic testing, counseling, and reporting; and

WHEREAS the parties desire to set forth the scope, terms, risks, uses of results, and payment terms pertaining to the genetic testing requested.

PATIENT INFORMATION

Month:   Day:   Year:

SCOPE OF WORK

Description of testing, procedures, and deliverables: complete description provided below. Provider will perform testing consistent with standard clinical laboratory practices and applicable professional guidelines.

RISKS, LIMITATIONS, AND ALTERNATIVES

The Patient acknowledges that genetic testing may identify variants of uncertain significance, incidental or secondary findings, and that not all genetic conditions are detectable. Test sensitivity and specificity vary by test. Counseling regarding potential emotional, familial, and insurance-related implications is recommended prior to testing.

Yes   No

USE OF SPECIMEN AND DATA

Specimens and extracted DNA/RNA will be retained for the period necessary to complete testing and for quality assurance. De-identified specimens may be retained for method validation unless Patient declines below.

I consent to de-identified storage and potential future internal research and method validation.

I decline storage for research or validation purposes beyond clinically necessary retention.

RESULTS, REPORTING, AND RELEASE

Results will be provided in a written report to the ordering clinician. Results may include clinically actionable findings and incidental findings as defined by current professional guidance. By signing below, Patient authorizes release of results to ordering clinician and persons indicated in the release authorization.

PAYMENT TERMS

Patient or payer is responsible for payment for services performed. Provider will bill insurance if authorized; Patient remains responsible for amounts not covered by insurance, co-payments, deductibles, and any collection costs.

TERM AND TERMINATION

This Agreement commences on Start Date and continues until End Date or until services are completed or terminated under the notice provisions below.

Start Date: Month:   Day:   Year:

End Date: Month:   Day:   Year:

CONFIDENTIALITY

Provider shall maintain confidential all Patient medical and genetic information in accordance with applicable law. Provider may disclose information to the ordering clinician, authorized recipients, billing agents, and as required by law. De-identified information may be used for quality improvement, validation, and education without further authorization unless otherwise restricted by Patient selection above.

WITHDRAWAL OF CONSENT

Patient may withdraw consent in writing before testing is performed. Withdrawal is not effective for disclosures already made in reliance on this consent. Withdrawal does not affect payment obligations for services already rendered.

GOVERNING LAW

This Agreement and any dispute arising out of or related to it shall be governed by the laws of the State of , without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between Patient and Provider regarding the subject matter herein and supersedes all prior oral or written agreements. Any amendment must be in writing and signed by both parties.

PATIENT AUTHORIZATION AND CERTIFICATION

By signing below, Patient certifies that they have read and understand the information provided in this form, that the nature and purpose of the genetic testing has been explained, that risks and alternatives have been discussed, and that Patient authorizes the Provider to perform the described genetic testing and to release results as authorized above. Patient acknowledges financial responsibility as described.

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