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_________________________________________________________________________________________________________________________
FirstName MiddleName LastName
______________________________________________________________________________________________________________________________________________________________________________________
StreetAddress
______________________________________________________________________________________________________________________________________________________________________________________
City State ZipCode
HomePhone:________________________________________________________ Gender: ☐Male☐FemaleDOB(mm/dd/yyyy):________________________________
Ancestry:☐AfricanAmerican☐Caucasian☐Hispanic☐European☐MiddleEastern☐Asian☐Ashkenazi-Jewish☐Central/SouthAmerican
☐Other_______________________________________________________
Thistestismedicallynecessaryfortheriskassessment,diagnosisordetectionofadisease,illness, impairment,symptom,syndromeordisorder.Theresults
willdeterminemypatient’smedicalmanagementandtreatmentdecisions.Bymysignaturebelow,I indicatethatIamthereferringphysicianorauthorized
healthcareprovider.Ihaveexplainedthepurposeofthetest.Thepatienthasbeengiventheopportunitytoaskquestionsand/orseekgeneticcounseling.The
patienthasvoluntarilydecidedtohavethetestperformedbymyGenomics.
__________________________________________________________________________________________________________
MedicalProfessionalSignature(required) Date(mm/dd/yyyy)
Signhereorontheconsentdocument.
IhavereadtheInformedConsentdocumentandgivemypermissiontomyGenomicstoperformgenetictestingasdescribed.Ialsogivepermissionformy
specimenandclinicalinformationtobeusedinde-identifiedstudiesatmyGenomicstoimprovegenetictestingandforpublication,ifappropriate.Mynameor
otherpersonalidentifyinginformationwillnotbeusedinorlinkedtotheresultsofanystudiesandpublications.IalsogivemyGenomicspermissiontoinform
meinthefutureaboutresearchopportunities,includingtreatmentsfortheconditioninmyfamily.
! Checkthisboxifyouwanttooptoutofresearchstudies.!Checkthisboxifyoudonotwishtobecontacted.
! CheckthisboxifyouareaNYresidentandgivemyGenomicspermissiontoretainanyremainingsamplelongerthan60daysafterthecompletionoftesting.
________________________________________________________________________________________
Patient/GuardianSignature Date(mm/dd/yyyy)
BillingType: !CommercialInsurance !Medicare!Medicaid Priorauthorization#:_______________________________________________________________________
Pleasecompletethefollowingandattachacopyofthefrontandbackofthepatient’sinsurancecard(includesecondarywhenapplicable).
_______________________________________________________________________________________________ /___________________________________________________________________________________________________________
PrimaryInsuranceCarrier ID# Group# SecondaryInsuranceCarrier ID# Group
_______________________________________________________________________________________________/___________________________________________________________________________________________________________
NameofInsuredPerson RelationshiptoPatient NameofInsuredPerson RelationshiptoPatient
_______________________________________________________________________________________________ /___________________________________________________________________________________________________________
InsuredDateofBirth Startdateofcoverage InsuredDateofBirth Startdateofcoverage
_________________________________________________________________________________________________________________________
PracticeName ProviderName ProviderNPI#
______________________________________________________________________________________________________________________________________________________________________________________
StreetAddress
______________________________________________________________________________________________________________________________________________________________________________________
City State ZipCode
OfficePhone:__________________________________________OfficeFax:__________________________________________Email:_____________________________________________________________
AdditionalPhysicianorGeneticCounselortobecopied:Name:__________________________________________________________________Fax#:____________________________________
PATIENTINFORMATION
ORDERINGACCOUNTINFORMATION
PHYSICIANAUTHORIZATION
PATIENTAUTHORIZATION
BILLINGINFORMATION
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com
CancerTestRequisitionFormCollectionDate(mm/dd/yyyy):____________________________
OfficeUseOnly:DateReceived:____________________________________________________________
SpecimenType:!Buccal!Blood(2mLinlavendertoptube)
!Saliva!Other_________________________________
MGV101/REV 09-16
PERSONALHISTORYOFCANCER(S)ORTUMOR(S) ☐ NoPersonalHistoryofCancer/Tumor
☐ BreastCancer AgeofDiagnosis:______________
☐ER☐PR☐HER2☐TripleNegative☐Bilateral☐TwoPrimaries☐InvasiveDuctal☐InvasiveLobular☐DCIS☐LCIS☐Other:____________________________________________
☐ OvarianCancer AgeofDiagnosis:__________________
☐Serous☐Mucinous☐Endometrioid☐ ClearCell ☐LMP/Borderline☐Other:__________________________________________________________________
☐ EndometrialCancerAgeofDiagnosis:______________☐Serous☐Mucinous☐Endometrioid☐ClearCell☐Sarcoma☐Other:____________________________________________________________
☐ PancreaticCancerAgeofDiagnosis:_________________☐Adenocarcinoma☐IPMN☐Neuroendocrine☐Other:__________________________________________________________________
☐ ColorectalCancerAgeofDiagnosis:______________Location:☐Right☐Left☐Transverse☐Rectum
☐Melanoma AgeofDiagnosis:__________________
☐Invasive☐In-Situ☐ ProstateCancer AgeofDiagnosis:______________☐GleasonScore:__________________________________________________☐Other:___________________________________________________________
☐ Polyp(s) AgeofFirstPolyp:_________________
☐Adenomatous–total#:______________________________________________☐Other–Pathology:_______________________________Total#:__________
☐ GastricCancer/TumorAgeofDiagnosis:______________Pathology:________________________________________________________
☐ BrainCancerAgeofDiagnosis:___________________Pathology:_____________________________________________________________
☐ EndocrineCancer/DiseaseAgeofDiagnosis:______________☐ThyroidPathology/Diagnosis:______________________________☐Pheochromocytoma(PCC)☐Paraganglioma(PGL)Location:_______________________________
☐ RenalCancer AgeofDiagnosis:__________________
☐Bilateral☐ClearCell☐PapillaryType(IorII):______________________________________________☐TransitionalCell☐Other__________________________________________
☐ HematologicDisease AgeofDiagnosis:_______________
Diagnosis:______________________________________________________________
Status:☐Active/ResidualDisease☐Remission
☐ OtherCancer/Tumor________________________________________
AgeofDiagnosis:______________________________________________
FAMILYHISTORYOFCANCER(S)ORTUMOR(S)
☐ NoKnownFamilyHistoryofCancer(s)orTumor(s)☐PedigreeAttached☐AdoptedPleaseincludeallclinicaldetails,suchasbilateral,pathology(includingtriplenegativebreastcancer),premenopausalbreastcancer,
andGleasonscoreforprostatecancer,ifavailable.
Relationship Maternal Paternal Cancer/TumorSite AgeatDiagnosis
________________________________________ ☐ ☐ __________________________________________________________ ____________________________________________________________ ☐ ☐ __________________________________________________________ ____________________________________________________________ ☐ ☐ __________________________________________________________ ____________________________________________________________ ☐ ☐ __________________________________________________________ ____________________
PERSONALGENETICTESTINGHISTORY(Pleaseincludeallcopiesoftestsandrelatedmedicalrecords.)☐ NoPersonalHistoryofGeneticTesting
☐ Gene(s)Tested:_______________☐Positive☐Negative/_______________☐Positive☐Negative/_______________☐Positive☐Negative_______________☐Positive☐Negative/_______________☐Positive☐Negative/_______________☐Positive☐Negative
PREVIOUSFAMILIALGENETICTESTING☐ NoFamilyHistoryofGeneticTesting☐RelativeTested:______________________________Gene(s)Tested:________________________☐Positive☐Negative☐VUS(VariationofUnknownSignificance)
PatientName:____________________________________
DateofBirth:________________________
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16
�HC0001 AdenomatousPolyposisPanel(2Genes)
APC,MUTYH
ApplicableICD-10codesmayinclude:�D12.0�D12.1�D12.2�D12.3�D12.4�D12.5�D12.6
�D12.7�D12.8�D37.4�D37.5�D48.1�D49.0�Z83.71�Z86.010�Z87.39
OtherICD-10codes:_____________________________________________________________________________________________
�HC0003 BreastCancerHigh/ModRiskPanel(8genes)
ATM,BRCA1,BRCA2,CDH1,CHEK2,PALB2,PTEN,TP53
ApplicableICD-10codesmayinclude:�C50.929�D05.00�D05.90�D07.30�Z15.01�Z15.02
�Z80.3�Z80.41�Z80.42�Z84.81�Z85.3�Z85.43�OtherICD-10codes:__________________________
�HC0004 BreastCancerPanel(44Genes)
ACVR1B,AKT1,ATM,BAP1,BRCA1,BRCA2,CBFB,CDH1,CDKN2A,EGFR,EP300,ERBB2,
ERBB3,ESR1,EXOC2,EXT2,FBXO32,FGFR1,FGFR2,GATA3,IRAK4,ITCH,KMT2C,MAP2K4,MAP3K1,MDM2,MUC16,MYC,NCOR1,NEK2,PBRM1,PCGF2,PIK3CA,PIK3R1,
PPM1L,PTEN,PTGFR,RB1,RET,SEPT9,TP53,TRAF5,WEE1,ZBED4,
ApplicableICD-10codesmayinclude:�C50.929�D05.00�D05.90�D07.30�Z15.01�Z15.02�Z80.3�Z80.41�Z80.42�Z84.81�Z85.3�Z85.43�OtherICD-10codes:__________________________
�HC0005 Breast/OvarianCancerPanel(21Genes)
ATM,BARD1,BRCA1,BRCA2,BRIP1,CDH1,CHEK2,EPCAM,FANCC,MLH1,MSH2,MSH6,NBN,PALB2,PMS2,PTEN,RAD51C,RAD51D,STK11,XRCC2,TP53
ApplicableICD-10codesmayinclude:�C50.929�D05.00�D05.90�D07.30�Z15.01�Z15.02�Z80.3�Z80.41�Z80.42�Z84.81�Z85.3�Z85.43�OtherICD-10codes:__________________________
�HC0006 OvarianCancerPanel(32Genes)
AKT1,ARID1A,BRAF,BRCA1,BRCA2,CBLC,CCNE1,CDK12,CDKN2A,CSMD3,CTNNB1,
CUBN,EGFR,ERBB2,FAT3,GABRA6,KIT,KRAS,KREMEN1,MAS1L,MLH1,MSH2,NF1,
NRAS,PDGFRA,PIK3CA,PIK3R1,PPP2R1A,PTEN,RB1,TP53,USP16ApplicableICD-10codesmayinclude:�C50.929�D05.00�D05.90�D07.30�Z15.01�Z15.02�Z80.3�Z80.41�Z80.42�Z84.81�Z85.3�Z85.43�OtherICD-10codes:__________________________
�HC0007 ColorectalCancerPanel(38Genes)
ACVR1B,AKT1,APC,ATM,ATP6VOD2,BAX,BRAF,CASP8,CDC27,CTNNB1,DCC,DMD,
EP300,ERBB2,FBXW7,FZD3,GPC6,KRAS,MAP2K4,MAP7,MIER3,MLH1,MSH2,MSH3,
MSH6,MYO1B,NRAS,PIK3CA,PIK3R1,PTPN12,SLC9A9,SMAD2,SMAD4,TCERG1,
TCF7L2,TGFBR2,TP53,WBSCR17
ApplicableICD-10codesmayinclude:�C18.9�C19�C20�C21.0�D01.0�D01.1�D01.2
�D01.3�D01.40�D01.7�D01.9�K63.5�Z80.0�Z83.71�Z83.79�Z84.81�Z85.00
�Z86.010OtherICD-10codes:________________________________________________________________________________
�HC0008� EndocrineNeoplasiaPanel(7Genes)�
CDC73,HRAS,MEN1,PRKAR1A,PTEN,RET,VHL
ApplicableICD-10codesmayinclude:�C70.0�C70.1�C70.9�C75.0�C75.1�D09.3�D17.9
�D42.9�E21.5�E23.7�Z15.81�Z83.41�Z83.49�Z84.81�Z85.850�Z85.858
�OtherICD-10Codes:__________________________________________________________________________________________
�HC0009� EndometrialCancerPanel(12Genes)�
BRCA1,BRCA2,CHEK2,EPCAM,MLH1,MSH2, MSH6,MUTYH,PMS2,POLD1,PTEN,TP53ApplicableICD-10codesmayinclude:�N85.0�N85.00�C54.1�C54.2�Z15.04
�OtherICD-10codes:__________________________________________________________________________________________
�HC0010� GastricCancerPanel(29Genes)�
APC,ATP4A,BAI3,BRCA2,CCNE1,CDH1,CTNNB1,DCC,ERBB2,FBXW7,FGFR2,GPR78,
LPAR2,PRP1B,LRRK2,MET,MYC,NOTCH1,PIK3CA,PRKDC,RET,S1PR2,SPEG,SSTR1,STK11,TP53,TRIO,TRRAP,WNK2
ApplicableICD-10codesmayinclude:�C15.9�C16.9�C17.9�D00.1�D00.2�D05.90�Z80.0�Z84.81�Z85.00�OtherICD-10codes:____________________________________________________________________
�HC0011� Li-FraumeniSyndromeCancerPanel(2Genes)�
CHEK2,TP53
ApplicableICD-10codesmayinclude:�C41.9�C49.9�C50.919�C50.929�C71.9�C74.90
�D05.00�D05.10�D05.90�D09.8�D43.2�D43.4�Z85.830
�OtherICD-10codes:__________________________________________________________________________________________
PatientName:____________________________________
DateofBirth:________________________
�HC0002 BreastBasicCancerPanel(2genes)
BRCA1,BRCA2ApplicableICD-10codesmayinclude:�C50.929�D05.00�D05.90�D07.30�Z15.01�Z15.02
�Z80.3�Z80.41�Z80.42�Z84.81�Z85.3�Z85.43�OtherICD-10codes:__________________________
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16
�HC0013 LungCancerPanel(45Genes)
AKT1,ALK,APC,ATM,BAI3,BAP1,BRAF,CDKN2A,EGFR,EPHA5,ERBB2,ERBB4,FBXW7,FGFR1,FGFR2,GRM8,KDR,KEAP1,KIT,KMT2D,KRAS,LRP1B,MDM2,MET,MLH1,MUC16,MYC,NF1,
NFE2L2,NOTCH1,PDGFRA,PIK3CA,PIK3CG,PKHD1,PTEN,RARB,RB1,RET,ROS1,RUNX1T1,
SMAD4,SMARCA4,SOX2,STK11,TP53+in/del
ApplicableICD-10codesmayinclude:�D38.1�C34.80�C34.90�C34.12�C34.81�C34.82�Z85.118�Z80.1�OtherICD-10codes:___________________________________________________________________
�HC0014 Lynch/ColorectalCancerPanel(8Genes)
APC, EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, PTENApplicableICD-10codesmayinclude:�C18.9�C19�C20�C21.0�D01.0�D01.1�D01.2
�D01.3�D01.40�D01.7�D01.9�K63.5�Z80.0�Z83.71�Z83.79�Z84.81�Z85.00
�Z86.010OtherICD-10codes:________________________________________________________________________________
�HC0015 MelanomaCancerPanel(13Genes)
BAP1, BRCA2, CDK4, CDKN2A, MC1R, MITF, NF1, PTEN, RB1, TP53, VH1, XPA, XPCApplicableICD-10codesmayinclude:�C25.9�C43.9�D01.7�D01.9�D03.9�D04.9�Z80.0
�Z80.8�Z84.81�Z85.820�OtherICD-10codes:________________________________________________________
�HC0016 PachyonychiaCogenitaPanel(9Genes)
AAGAB, DSG1, GJB6, KRT6A, KRT6B, KRT6C, KRT16, KRT17, TRPV3ApplicableICD-10codesmayinclude:�Q84.3�Q84.4�Q84.5�Q84.6
�OtherICD-10codes:_________________________________________________________________________________________
�HC0017 PancreaticCancerPanel(16Genes)
APC,ATM,BRCA1,BRCA2,CDK4,CDKN2A,EPCAM,MLH1,MSH2,MSH6,PALB2,PMS2,STK11,
TP53,VHL,XRCC2
ApplicableICD-10codesmayinclude:�C25.9�C80.1�D01.7�D01.9�Z80.0�Z84.81�Z85.07
�OtherICD-10codes:_________________________________________________________________________________________
�HC0018 ProstateCancerPanel(32Genes)
AKAP9,APC,AR,CDK12,CDKN1B,CDKN2A,GLI1,IKZF4,KDM4B,KLF6,KMT2D,MED12,MYC,
NCOA2,NIPA2,NKX3-1,NRCAM,OR5L1,PDZRN3,PIK3CA,PTEN,RB1,SCN11A,SPOP,SYNE3,TBX20,TFG,THSD7B,TP53,ZFHX3,ZNF473,ZNF595
ApplicableICD-10codesmayinclude:�D07.5�R97.2�Z15.03�Z80.41�Z80.42�Z84.81�Z85.46�OtherICD-10codes:_________________________________________________________________________________________
�HC0019 RenalCancerPanel(19genes)
BAP1,EPCAM,FH,FLCN,MET,MITF,MLH1,MSH2,MSH6,PMS2,PTEN,SDHA, SDHB,SDHC,SDHD,TP53,TSC1,TSC2,VHL
ApplicableICD-10codesmayinclude:�C64.9�C65.1�C65.2�C65.9�V16.51�OtherICD-10codes:________________________________________________________________________________________
�HC0020 TruSight Cancer Predisposition panel (94 Genes+284SNPs)
AIP,ALK,APC,ATM,BAP1,BLM,BMPR1A,BRCA1,BRCA2,BRIP1,BUB1B,CDC73,CDH1,CDK4,
CDKN1C,CDKN2A,CEBPA,CEP57,CHEK2,CYLD,DDB2,DICER1,DIS3L2,EGFR,EPCAM,ERCC2,
ERCC3,ERCC4,ERCC5,EXT1,EXT2,EZH2,FANCA,FANCB,FANCC,FANCD2,FANCE,FANCF,FANCG,
FANCI,FANCL,FANCM,FH,FLCN,GATA2,GPC3,HNF1A,HRAS,KIT,MAX,MEN1,MET,MLH1,MSH2,MSH6,MUTYH,NBN,NF1,NF2,NSD1,PALB2,PHOX2B,PMS1,PMS2,PRF1,PRKAR1A,PTCH1,PTEN,
RAD51C,RAD51D,RB1,RECQL4,RET,RHBDF2,RUNX1,SBDS,SDHAF2,SDHB,SDHC,SDHD,SLX4,
SMAD4,SMARCB1,STK11,SUFU,TMEM127,TP53,TSC1,TSC2,VHL,WRN,WT1,XPA&XPC
�ICD-10codes:________________________________________________________________________________________________
�HC0021 HereditarySingleGeneorGeneSet RequestedGene(s):____________________________________________________________________________________________�
�ICD-10codes:________________________________________________________________________________________________
�HC0022 VariantTesting(previouslyidentifiedfamilialmutation)
Requested Gene(s): ____________________________________________________________________________________________�
�ICD-10codes: ________________________________________________________________________________________________
�HC0023 FocusedExomeTesting(5,500genes)
�ICD-10codes:________________________________________________________________________________________________
�HC0024 WholeExomeSequencingTRIO(22,000genes)
�ICD-10codes:________________________________________________________________________________________________
�HC0025 WholeExomeSequencingPROBAND �ICD-10codes:________________________________________________________________________________________________
�HC0026 WholeExomeSequencingAdditionalFamilyMember
�ICD-10codes:________________________________________________________________________________________________
�HC0027 WholeGenome �ICD-10codes:________________________________________________________________________________________________
�HC0012� LiverCancerPanel(33Genes)�
ALB, AMPH, APC, ARID1A, ARID2, ATM, AXIN1, BAZ2B, BRAF, CCDC178, CDKN2A, CSMD3, CTNNB1, DSE, ELMO1, ERBB2, ERRFI1, GXYLT1, IGF2R, IGSF10, KEAP1, KRAS, MET, NHF1A, OTOP1, PIK3CA, SAMD9L, TP53, UBR3, USP25, WWP1, ZIC3, ZNF226ApplicableICD-10Codesmayinclude:�C22.8�E83.11�OtherICD-10codes:_________________________
RequestedGene(s):____________________________________________________________________________________________�
�ICD-10codes:________________________________________________________________________________________________
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16
InformedConsentandAuthorizationForm
Iunderstandthatmyhealthcareproviderhasorderedthefollowinggenetictestingfor:☐Me☐MyChildSignature:__________________________________________________________
Whatisgenetictesting?Genetictestingisananalysisofaperson’sgeneticmakeup.Everyoneisbornwithadistinctsetofgenesthatisuniqueto
them. These genes provide instructions for the body to grow and develop. Sometimes a person’s genesmay be altered
during formation and could lead to a specific syndrome, disease or birth defect. Depending on the type of genetic test
ordered,ageneticconditionorseveralconditionscouldbedetectedthatincreaseyourriskofasyndrome,diseaseand/or
defect. Your provider or a genetic counselor should informyou about these conditions forwhichyou are being offered
testing.Youmayalsoneedtofollowupwithageneticcounselororyourprovidertodiscusstheresultsafterthetesting.
Whatisthepurposeofgenetictesting?Thegenetictestisconsideredapredictivetestifitisperformedtoidentifywhetherapatientisatanincreasedriskof
developingahereditarydefectordiseasebutdoesnotdetermineforcertainthatadefectordiseasewilloccur.Ifagenetic
testisbeingperformedafteradefectordiseasehasbeendiagnosedandthetestconfirmsthecausetobeinrelationtothe
gene(s),itisconsideredadiagnosticorconfirmatorytest.
Howisagenetictestperformed?Genetictestsareusuallyperformedbyeitherbloodtestingorobtainingtissueorcheekcellsamples.Thesesamples
containwhitebloodcellsthatcontainyourDNA,RNAandimportantproteins.Whentestingduringpregnancy,chorionic
villus,amnioticfluidorasampleofthemother’sbloodcanbeused.
Whatarethelimitationsofgenetictesting?Agenetictestmayprovideveryimportantinformationaboutyourhealthbuttherearelimitations:
• Performingthecorrecttest:Iftheproviderdoesnothaveanaccuratepersonalorfamilyhistorytodetermine
whichgenetictest(s)areimplicated,theincorrectorincompletetest(s)maybeordered.
• LaboratoryProcessing:Alllaboratoriesmustmeettheproperrequirementstoprocessyoursampleandstrict
guidelinesmaybeinplacetoensuretheserequirements;however,inrarecases,problemsmayoccurinhandling
thesample,whichmightleadtoincorrectresults.
• ImplicationsofResults:Thegenetictestmayrevealanalterationinageneorseveralgenesbuttheremaybelimits
towhatisknownabouteachgeneandthesignificanceoftheresultmaybeuncertain.Ageneticalterationor
variationcannotdeterminewhetheryouwillactuallydevelopasuspectedcondition,thetimingofitsdevelopment
ortheseverityofthecondition.
Itisimportantthatyoudiscussyourgenetictestresultwithyourprovidersothatyoucanmakeaninformeddecision
aboutyournextsteps.
Whatarethebenefitsofgenetictesting?Thereareseveralbenefitstoperforminggenetictesting.Ifageneticvariationisdetermined,
• Theremaybepreventivemeasuresoridentifiedmedicaltreatmentsthatdecreaseyourchancesofdevelopinga
relatedgeneticsyndrome,diseaseordefect.
• Theknowledgecanempowerapersontomakeimportantchoicesaboutlifeplanning,evenifacureisnotavailable
atthetimeoftesting.
• Apersonmayqualifytoenrollinarelatedresearchstudy,whichmayleadtonewtreatments.
• Itmayprovideimportanthealthinformationforaperson’sfamily.
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16
Whataretherisksofgenetictesting?Therearepossiblerisksofgenetictesting:
• Althoughlowrisk,theremaybeaphysicalriskinvolvedinobtainingthesamplefortesting.
• Therearepotentialpsychologicalandsocialrisksoftestingbecausetheycanchangeaperson’slifeperspective.It
maybestressfulandtheremaybeanemotionalreactiontolearningaboutrisksforyourselforyourfamily.Thisis
whyitisimportanttodiscussthetestingwithyourprovideroraGeneticCounselorbeforetesting.
• Therearepossibleeconomicrisksofgenetictestingthatmayinterferewithapatient’sabilitytoobtainhealth,life,
disabilityorlong-termcareinsurance.
• Thegenetictestresultswillbecomeapartofyourmedicalrecord.Ifagenetictestisperformed,yourinsurance
companymayhaveaccesstotheresult.
• Therearebothstateandfederallawsthatweredevelopedtohelpprotectapersonfromgeneticdiscrimination,
whichisthemisuseofgeneticinformation.GINAistheGeneticInformationNondiscriminationActof2008andisa
federallawthatprotectsindividualsfromgeneticdiscriminationinhealthinsuranceandemployment.
WhatcanIlearnfrommygenetictestresult?Resultscanbeclassifiedasnegativeorpositive.
• Anegativeor“normal”resultmeansthetestdidnotdetectavariationorchangeinthegene(s)tested.Thismayhave
limitationsinthatallgenesrelatedtoaparticularconditionmaynothavebeentested.Therefore,anegativetest
doesnotalwaysruleoutthedevelopmentofaproblematicgeneticcondition.Also,technologyimproveseveryyear
andtheremaybenewdiscoveriesthatareassociatedwithaparticulargeneticconditionthatwasunknownatthe
timeoftesting.
• Apositiveor“abnormal”resultmeansthatyouhaveageneticchangeorvariationthatisrelatedtothedevelopment
ofaspecificgeneticconditionthatmayputyouatanincreasedrisk.However,notallgenevariationsleadto
symptomsorthedevelopmentofthegeneticcondition.
• Aninconclusiveresultmeansthatitmayfallbetweena“normal”or“abnormal”rangeorbe“indeterminate.”Insuch
cases,thismaybelabeledasaVUSorvariantofunknownsignificance.Eventhoughachangeinthegenemaybedetected,thelaboratorymaynothaveenoughinformationtodetermineifthegeneplacesapersonatanincreased
risk.Laboratoriesmaylearnmoreaboutthatvariantinthefutureandbeabletomakeamoredefinitivedecision
aboutthesignificanceofthegenevariation.
• Inrarecases,agenetictestmayrevealanimportantgeneticvariationthatisnotdirectlyrelatedtothereasona
providerorderedthetest.Theseresultsarecalledsecondaryorincidentalfindings.Examplesmayinclude:
- Non-paternity:Thepersondesignatedasthefatherisnotthebiologicalfatherofthepersonhavingtesting.
- Consanguinity:Thebiologicalparentsarecloselyrelatedbyblood.
- Identificationofaconditionunrelatedtothereasonfortesting
Resultinterpretationisbasedoncurrentandavailableinformationpresentinmedicalliterature,researchandscientific
databases.Becausetheseresourcesareconstantlychanging,newinformationthatbecomesavailableinthefuturemayreplace
oraddtotheinformationmyGenomicsusedtointerpretaperson’stestresults.myGenomicsdoesnotroutinelyre-analyzetestresultsthathavealreadybeenissuedandhasnoobligationtodoso.Apersonmaymonitorpubliclyavailableresources
suchasClinVar(www.clinvar.com)tolearnaboutcurrentinformationabouttheclinicalinterpretationofagenetictest.
Whathappenstomysampleaftertesting?DNAsamplesarenotreturnedtoapersonafterthetesthasresulted.De-identifiedsamplesandde-identifiedtestresults
maybestoredinarepositoryandusedforinternalvalidation,educational,researchpurposesincludingHIPAA-compliant
databasesorpresentedinscientificpresentationsorpapers.
Researchwithde-identifiedsamplesandtestdatathatresultsinmedicaladvancesmayhavepotentialcommercialvalueand
maybedevelopedandownedbymyGenomicsortheresearcherswhoanalyzethedata.Ifanyindividualorcorporation
benefitsfinanciallyfromstudyingaperson’sde-identifiedgeneticmaterial,nocompensationwillbeprovidedtotheperson
orperson’sheirs.
myGenomicshasnoobligationtoretainaperson’ssampleindefinitelyandmaydestroyitonceitnolongerhasalegaldutytoretainit.Byconsentingtothisagreement,IprovideauthorizationformyGenomicsanditspartnerstousemyormychild’s
de-identifiedsampleandtestresultsforsuchpurposesasmentionedabove.
Unlessoptedoutonthefirstpageoftherequisition,myGenomicsmaycontactmeinthefutureregardingtheopportunityto
participateinresearchopportunities,includinganyavailabletreatmentformyselfand/ormyfamily.
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16
☐ IunderstandthatImaycontactmyGenomicsviaemailatinfo@mygenomics.comorbyphoneat1-855-647-4363ifIwish
tooptoutoffuturecontactorhaveanyquestionsrelatedtomytestresults.
☐ IunderstandthatsamplesfromresidentsofNewYorkStatewillnotbeincludedinthede-identifiedresearchstudiesdescribedinthis
authorizationandwillnotberetainedformorethan60daysaftertestcompletion,unlessspecificallyauthorizedbymyselectionbelow.
TheauthorizationisoptionalandtestingwillnotbeaffectedifIdonotchecktheboxfortheNewYorkauthorizationlanguage.
☐ InternationalSpecimens:IfmychildorIresideoutsideoftheUnitedStates,Iattestthatbyprovidingasamplefortesting,Iamnotknowinglyviolatinganyexportbanorotherlegalrestrictioninthecountryofmyormychild’sresidence.
☐ PatientConfidentialityandGeneticCounseling:ItisrecommendedthatmychildorIreceivegeneticcounselingbeforeandafterthegenetictest.Furthertestingorconsultationswithahealthcareprovidermaystillbenecessary.Tomaintainconfidentiality,thetestresults
willonlybereleasedtothereferringhealthcareprovider,totheorderinglaboratory,tomeorotherhealthcareprovidersinvolvedinmy
ormychild’sdiagnosisandtreatment,ortoothersasentitledbylaw.TheUnitedStatesFederalGovernmenthasenactedseverallawsthat
prohibitdiscriminationbasedongenetictestresultsbyhealthinsurancecompaniesandemployers.Inaddition,theselawsprohibit
unauthorizeddisclosureofthisinformation.Formoreinformation,IunderstandthatIcanvisitwww.genome.gov/10002077.
PatientAcknowledgement:Byagreeingtothisauthorization,Iacknowledgethefollowing:• Iameither(1)thepatientprovidingthesampleandamatleast18yearsofageor(2)Ihavelegalauthorizationtoprovidethisinformed
consentonbehalfofanotherperson.
• Ihavereadandagreetothecontentsofthisform.
• Iunderstandthebenefits,risksandlimitationsofgenetictesting.
• Irecognizetheseriousnessofconditionsforwhichtestingisbeingordered,andthatdiseasedescriptions,prognoses,andtreatment
optionshavebeenmadeavailabletomebymyormychild’shealthcareprovider.
• Ihavebeeninformedoftheavailabilityofgeneticcounselingservices.Icanfindageneticcounselorinmyareaat:www.nsgc.org.
• Iwillbegiventheopportunitytodiscusstheresultsofthetestwithmyhealthcareprovider,onceIreceivethem.
• Iamresponsibleforinformingmyorderinghealthcareproviderofchangesinmyormychild’sfamilyhistory.
• IunderstandthatmyGenomicsmaycontactmeinthefutureforresearchopportunities,includingtreatmentsfortheconditioninwhich
myormychild’sfamily.(PleasechecktheboxattheendofthisAuthorizationifyouwishtooptoutoffutureresearchopportunities.)
• IunderstandthatmyGenomicsmayusemyormychild’sde-identifiedinformationandtestresultsforvalidation,educationaland/or
researchpurposes,andthisde-identifieddatamaybesubmittedinaHIPAA-compliantmannertoresearchdatabases.
• Fortestsorstudiesthatgeneratedatafrommultiplefamilymembersormyspouseorpartner,Iconsenttoallofthedatabeingincluded
inasinglecomprehensivereportthatwillbesharedwithparticipatingfamilymembers,myspouseorpartner.
• IfmyGenomicsoracontractedpartnerofmyGenomics(collectively,“myGenomicsPartners”)isbillingmymedicalinsurancecarrier
directly,IrepresentthatIamcoveredbyinsuranceandauthorizemyGenomicsPartnerstogivemydesignatedinsurancecarrier,health
plan,orthirdpartyadministrator(collectively,“Plan”)theinformationonthisformandotherinformationprovidedbymyhealthcare
providernecessaryforreimbursement,andIauthorizePlanbenefitstobepayabledirectlytomyGenomicsPartners.
• IauthorizemyGenomicsPartnerstoinformmyPlanofmytestresult(s)onlyifthetestresult(s)arerequiredforpreauthorizationof,or
paymentfor,additionaltesting.
• IwillcooperatefullywithmyGenomicsPartnersbyprovidingallnecessarydocumentsneededforinsurancebillingandappeals;and
understandthatIamresponsibleforsendingmyGenomicsPartnersany,andall,ofthemoneythatIreceivedirectlyfrommyinsurance
companyinpaymentforthethistest.Reasonablecollectionand/orattorney’sfees,includingfilingandservicefees,shallbeassessedif
theaccountissenttocollection,aspermittedbystatelaw.Ipermitacopyofthisauthorizationtobeusedinplaceoftheoriginal.
• Finally,ifIhavethelegalauthorizationtoprovidethisinformedconsentonbehalfofanotherperson,Iamattestingthatthesample
providedbelongstothatperson.
Patient/GuardianAuthorizationBymysignaturebelow,Iattestthefollowing:IhavereadandIunderstandtheinformationprovidedonthisform.
OptOutforResearchandContact
☐ Idonotwishtoparticipateinanyresearchstudies.
☐ IdonotwishtobecontractedbymyGenomicsforfutureresearchopportunities.Iunderstandthatmyelectiontooptoutofsuchfollow
upcontactswillnotaffectmyabilitytoobtaintesting.
AuthorizationofNewYorkResidents
☐ IamaNewYorkstateresidentandIgivepermissionformyGenomicstoretainanyremainingsamplelongerthan60daysafter
completionoftestingandusemyde-identifieddataforscientificandmedicalresearchpurposes.Suchauthorizationisoptionalandisnot
requiredfortesting.
Patient/GuardianName:__________________________________________________________________________________________________________________________
FirstName MiddleName LastName DateofBirth:mm/dd/yyyy
Patient/GuardianSignature:__________________________________________________________________________________Date:______________________________
mm/dd/yyyy
HealthCareProvider’sStatementThistestismedicallynecessaryfortheriskassessment,diagnosisordetectionofadisease,illness,impairment,symptom,syndromeordisorder.
Theresultswilldeterminemypatient’smedicalmanagementandtreatmentdecisions.Bymysignaturebelow,IindicatethatIamthereferring
physicianorauthorizedhealthcareprovider.Ihaveexplainedthepurposeofthetestdescribedabove.Thepatienthasbeengiventheopportunity
toaskquestionsand/orseekgeneticcounseling.ThepatienthasvoluntarilydecidedtohavethetestperformedbymyGenomics.
HealthCareProvider’sSignature_____________________________________________________________________________Date:______________________________
mm/dd/yyyy
CLIA#11D2084528 11535ParkWoodsCircle,SuiteE;Alpharetta,GA30005 1-855-647-4363 www.mygenomics.com MGV101/REV 09-16