This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your healthcare information.
I have had a chance to review the Notice of Privacy Practices as part of this registration process (available in the Patient Portal and as listed below).
Advanced Tele-Genetic Counseling’s Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. YOUR RIGHTSWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record• You can ask us to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.• We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.• If you pay for a service or health care item out-of-pocket in full, you can ask us not toshare that information for the purpose of payment or our operation with your health insurer. We will say “yes” unless a law requires us to share that information.Advanced Tele-Genetic Counseling (AT-GC), LLC is currently out of network with most insurance providers and does not provide information to your insurance for out-of-pocket payments. If you choose to submit a receipt to your insurance provider for reimbursement, your insurer may ask AT-GC to provide additional information.Get a list of those with whom we’ve shared information• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost- based fee if you ask for another one within 12 months.
Get a copy of this privacy notice• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.• We will make sure the person has this authority and can act for you before we take any action. Please send any documentation of a medical power of attorney or legal guardianship to firstname.lastname@example.org.
File a complaint if you feel your rights are violated• You can complain if you feel we have violated your rights by contacting us using the information on the back page.• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/ complaints/.• We will not retaliate against you for filing a complaint.
YOUR CHOICESFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases you have both the right and choice to tell us to:• Share information with your family, close friends, or others involved in your care• Share information in a disaster relief situation• Include your information in a hospital directory
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:• Marketing purposes• Sale of your information• Most sharing of psychotherapy notes
Advanced Tele-Genetic Counseling (AT-GC), LLC is a privately owned company and does not create or manage a hospital directory. We will not sell your information or use it for marketing or fundraising purposes.
OUR USES AND DISCLOSURESHow do we typically use or share your health information?We typically use or share your health information in the following ways.
Treatment• We can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Health Care Operations• We can use and share your health information to run our practice, improve your care, and contact you when necessary.Example: We use health information about you to manage your treatment and services.
Billing or Payment for Services• We can use and share your health information to bill and get payment from health plans or other entities.Example: We give information about you to your health insurance plan so it will pay for your services.Advanced Tele-Genetic Counseling (AT-GC) is not currently in network with any insurance providers, so it is uncommon for us to routinely share information with your health insurance provider. If you choose to submit a receipt for services rendered by AT-GC to your health insurance provider for reimbursement, AT-GC may be contacted by your insurer to provide additional information for coverage of related health services. In this event, we will reach out to you and confirm your knowledge of this request and if you wish for us to comply. For self-pay patients, your personal information is used for payment (i.e. your credit card company).
How else can we share your health information?We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public and safety issuesWe can share health information about you for certain situations such as:
o PreventingDiseaseso Helping with product recallso Reporting adverse reactions to medicationso Reporting suspected abuse, neglect, or domestic violenceo Preventing or reducing a serious threat to anyone’s health or safety
Do research• We can use or share your information for health research.
Comply with the law• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Respond to organ and tissue donation requests• We can share health information about you with organ procurement organizations.Work with a medical examiner or funeral director• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information about you:o For workers’ compensation claimso For law enforcement purposes or with a law enforcement officialo With health oversight agencies for activities authorized by lawo For special government functions such as military, national security, andpresidential protective services
Respond to lawsuits and legal actions• We can share health information about you in response to a court or administrative order, or in response to a subpoena.
OUR RESPONSIBILITIES• We are required by law to maintain the privacy and security of your protected health information.• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.• We must follow the duties and privacy practices described in this notice and give you a copy of it.• We will not use or share your information other than described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and on our web site.If you have any questions or concerns regarding this notice, please email email@example.com with “Privacy” in the subject line or via mail to:
Advanced Tele-Genetic Counseling (AT-GC)
Attn: Privacy Officer4330 Glenview Ave, Suite 111Glenview, Kentucky 40025
[Effective Date: 08-27-2020]
"I understand that the terms of the Notice of Privacy Practices may change and I may obtain these revised notices by contacting the practice by phone or in writing.
I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.
I, with my e-signature, authorize Advanced Tele-Genetic Counseling (AT-GC), LLC, and its genetic counselors or medical staff, to provide care for me, or to this patient for which I am the legal guardian, in regard to genetic counseling and/or related genetics services. This care may include services and supplies related to my health (or the identified person). This consent includes contact and discussion with other health care professionals for care and treatment.
I, with my e-signature, acknowledge that the undersigned Patient or legally authorized representative of the Patient has received a copy, or a copy is available to me electronically at any time, of the Advanced Tele-Genetic Counseling Privacy Practices on the date listed below. A copy of the Notice of Privacy Practices is located in the AT-GC Client Patient Portal and on the AT-GC website.
If you need to contact our office between appointments, you may email our Care Team Coordinators at firstname.lastname@example.org or call the practice’s mainline at 888-252-2842. Clinicians are often not immediately available; however, your designated clinician will attempt to return your communication in a prompt manner. If an emergency situation arises, please call 911 or visit your local emergency room.
We cannot ensure the confidentiality of any form of communication through electronic media, including emails. While we make every attempt to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Communication through our patient portal is secure and confidential.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail are considered telehealth. Telehealth is broadly defined as the use of information technology to deliver medical services and information from one location to another.
You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed.
Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.There are potential risks, consequences, and benefits of telemedicine.
Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.
When using information technology in genetic counseling services, potential risks include, but are not limited to the genetic counselor’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformations, apparent height and weight, body type, gait and motor coordination, any noteworthy mannerism or gestures, and/or physical or medical conditions. Potential consequences thus include the genetic counselor not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the genetic counselor. As a result, the genetic counselor may inquire about these topics.
PATIENT RIGHTS AND RESPONSIBILITIES
You have scheduled an appointment with Advanced Tele-Genetic Counseling. Our genetic counseling providers are trained specialists that support patients and healthcare providers as they navigate the genetic counseling and testing process by collecting detailed personal and family health histories for patients, identifying specific genetic risks, assisting with coordination of the genetic testing process (as applicable), explaining relevant genetic information and information about genetic tests and their implications, and interpreting the specific genetic findings, their implications, and current research and preventative or management guidelines related to the personalized genetics results.
The genetic counselor or medical provider utilizes information provided by you and your healthcare provider, in conjunction with any existing relevant medical reports or genetic results, to assess your specific genetic risks; therefore, it is your responsibility to ensure that information provided to AT-GC is accurate. Please have relevant records and test results sent to AT-GC prior to your genetic counseling appointment and complete the intake information in the AT-GC Client Portal, including the family and personal health history questionnaire, to the best of your ability and no less than 48 hours before your appointment, when possible, so that the genetic counselor has time to study and prepare for your genetic consultation.
You are responsible for keeping your appointment. If you need to reschedule or cancel, please inform us at least 48 hours in advance of your scheduled consultation to avoid cancellation fees.
After providing your informed consent, if you are referred for initial, or pre-test, genetics services, you may decide to pursue genetic testing after speaking with the genetic counselor. Often, the genetic counselor or medical provider will help coordinate the testing for you. At times, you may be referred to your health care provider to help implement the test, though sample collection for genetic testing may also be available to you through in-home phlebotomy or mail-in saliva sample collection. These options will be discussed with you by the genetic counselor, as appropriate.
Results for most tests will be available in approximately eight days to eight weeks, though this varies by individual laboratory and requested test. All genetic test results received by AT-GC are reviewed by a certified genetic counselor. AT-GC’s team may attempt to contact you when your results are available to arrange a follow-up appointment and discuss the impact of your results.
AT-GC may attempt to contact you via telephone, email, or physical mail. Copies of the genetic testing results and clinic notes will be available in the AT-GC Client Portal. You may request a copy of your records from AT-GC.
As a patient, you have the right to be treated courteously and with respect. You also have the right to privacy for all electronic health records and individually-identifiable health information, as stated in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). At any time, you may request your electronic health record from Advanced Tele-Genetic Counseling. We are here to answer any questions or help with specialized concerns if the need arises.
For all patients, charges for genetic testing are separate from any charges incurred from genetic counseling and are specific to the laboratory performing the genetic testing. Please note that AT-GC is an independent provider of genetic counseling services; AT-GC is not a genetic testing laboratory.Please sign below to acknowledge your receipt, review, and understanding of the above information. Your tentative appointment time may not be confirmed as scheduled until we have received this completed form. Thank you.
WITH MY SIGNATURE BELOW, I DECLARE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
You are interested in finding out more about the impact of your genetic information on your health. Before agreeing to a telehealth consultation service with AT-GC’s practice, it is important that you read the following explanation.
AT-GC is dedicated to serving as a resource for genetic counseling and related services through telehealth. AT-GC utilizes telehealth to increase access to genetics care for those patients who want and need such services. This means that we use HIPAA-secure electronic methods for genetic consultation and evaluation. Consultations are performed remotely.
The decision to participate is completely up to you. Your decision will not affect your relationship with your regular doctor or your current or future medical care.
Please read this form carefully, or have it read to you. Feel free to take time to decide and discuss it with your healthcare provider before you make your decision whether or not you want to proceed. Ask questions about anything that is unclear and that you don’t understand or would like explained. You cannot undergo a consultation by AT-GC until you sign this form.
In the United States, your genetic information is protected by the Genetic Information Nondiscrimination Act (GINA). GINA is a federal law that generally makes it illegal for health insurance companies, group health plans, and most employers to discriminate against you based on your genetic information.
This law generally will protect you in the following ways:
As a patient, I understand the following about my genetic counseling consultation with AT-GC:
I understand that the conduct of engaging in consultation with AT-GC and its genetic counseling providers does not equate to an ongoing provider-patient relationship beyond genetics evaluation. I understand that I may request any information collected by AT-GC about me to be shared with myself or my healthcare provider so that my provider and I have this information for future knowledge and continuity of my care. The responsibility for follow-up care after an initial and/or results AT-GC consultation should remain with the patient and the patient’s local clinician.
When I share my physician’s contact information with AT-GC, I hereby authorize AT-GC to disclose my genetic information with the physician information I provide. If I do not have a local provideer, I can contact my state medical society to find a physician near me.
I understand that this consultation will not be the same as a direct patient/health care provider visit. In choosing to participate in a telemedicine consultation, I understand that the consultation will be performed remotely. I understand that I will be informed of the presence in the consultation of any clinical genetic counseling student undergoing rotation with AT-GC, and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to not participate in the consultation: and or (3) terminate the consultation at any time.
Benefits of AT-GC’s telehealth consultation include providing convenient virtual access to specialized genetics professionals and services, personalized genetics oversight, and increased knowledge about my own heredity and health. Remote consultations reduce the need for travel and time away for healthcare consultations. Remote consultations may provide more efficient medical evaluation and management. I understand that an AT-GC telehealth consultation has potential additional benefits including the availability and expertise of highly specialized genetic counselors to answer my questions during the process.
As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to, inadequate quality or scope of information, or unlikely but potential delays in evaluation and treatment due to electronic deficiency or failure. Though extremely unlikely, security protocols could fail. This would lead to a breach of privacy of personal medical information. I understand that a lack of access to complete medical records or my negligence in providing accurate personal medical and family may result in adverse judgment errors. Additional risks include technical difficulties and the limitation of not being physically present with the provider. I understand that my health care provider or I can discontinue the telehealth consultation if it is felt that the information is not adequate for the situation.
Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other geographic areas.
When AT-GC providers are involved with genetic testing selection, with patient consent and provider approval, AT-GC providers only utilize CLIA-certified laboratories when ordering genetic testing, which means that the laboratory must confirm all individual genetic testing results that will be returned to participants. Though CLIA-certified laboratory preference is considered, it ultimately remains the professional decision of the provider, in conjunction with the consent of the patient, as to which genetic testing resource, if any, may be most appropriate for the individual patient to utilize for the testing process of their genetic information.
If testing is deemed appropriate by a clinician, the genetic testing laboratory may have additional requirements for confirmatory testing, and it will remain my responsibility to communicate with the laboratory regarding processes and procedures to submit, process, and receive genetic testing results. It is important to note that any results returned by AT-GC will first be verified in the clinical lab utilized for testing.
Genetic testing results shared with AT-GC by genetic testing laboratories or providers will be uploaded into my AT-GC Client Portal and available for my download. All results reported to AT-GC will be reviewed by the AT-GC team. As results become available, AT-GC may attempt to contact me regarding my results. I have the opportunity to schedule a results consultation to talk through my results. AT-GC recommends that all patients schedule results consultations, but especially those with results that impact health, including those for which preventative measures exist, and those with a positive result indicating a known genetic mutation, with a variant (inconclusive) result, or those with a negative result but a strong personal or family history of symptoms indicative of heritable disease. At times, it is difficult to reach patients regarding their results. If I provide valid contact information, AT-GC may attempt to contact me (by email, physical mail, fax, or phone). I understand that I may contact the AT-GC team member involved with my care, call 888-252-2842, or email email@example.com with questions.
Sometimes the meaning of the genetic testing results may be uncertain. It is important to know that our understanding of genetics is changing quickly, and in many cases, we will not know for sure what the results mean for future health. Sometimes, even if we learn of a clear diagnosis, there will be no clear treatment. For many patients, only certain genes will be analyzed, so we will not find all gene variants that cause disease. One should not assume that a negative or variant test result means that all genetic risk has been evaluated since the specificity of genetic tests and the genes included often change as more knowledge is gained over time. I may recontact AT-GC to schedule an appointment to review any changes in result status. At times, should my result be reclassified and AT-GC made aware of this change through the genetic testing laboratory, AT-GC may recontact the patient, when possible.
I understand that if I am the parent or legal guardian of a minor for whom genetic services are deemed appropriate and for whom a referral from the child’s ongoing specialist has been received, the testing may reveal information relevant to my child’s or family’s health. Specifically, testing can indicate the presence of particular conditions, disease susceptibilities, or carrier statuses that are relevant for the children or their family members, but that do not affect children (i.e., adult-onset conditions). In accordance with current national guidelines recommending that minor children should not be tested for adult-onset disorders that require no diagnostic or therapeutic interventions prior to adulthood, and in order to honor the child’s autonomy (and the right to an open future), I understand that AT-GC will tell me only information directly related to diseases and disorders that affect children. My child can request additional information when they are 18.
If I have questions about my rights as a patient, or any additional questions, I can contact AT-GC.
Genetic testing is highly accurate, but limitations exist. The decision to engage in genetic testing may be stressful. There is no single test to detect all genetic conditions. I understand that in order for the genetic provider to accurately interpret my genetic risk for a particular indication, I must provide detailed genetic health medical and family history information, to the best of my knowledge. Providing this information accurately is paramount to the genetic counseling process.
When a mutation (gene change) is found, such as a gene change that confirms a suspected diagnosis (diagnostic testing), this result may not predict how severe the condition will be, while a gene change that indicates an increased risk for developing a condition in the future (predictive testing) cannot predict with certainty whether a person will develop the condition, or when symptoms will appear, and a gene change that shows a healthy person may eventually develop a condition (presymptomatic testing) does not tell exactly when or if the condition will occur.
Sometimes the genetic information one family member can disclose information about the genetic makeup of other relatives, even if they have not been tested. Certain genetic testing could reveal unexpected relationships or other secondary findings, such as non-paternity and consanguinity. I understand that other unexpected findings, such as identifying a genetic risk unrelated to the condition for which testing was being indicated, are possible. My results could potentially provide family members with important information about their risks; therefore, it may be important for me to share my results with my family, especially if the condition is preventable. I can discuss with my provider ways to share this information. I understand that the implications of the genetic results for my health or the health of my family may or may not be known at the time that the testing is completed.
CLIA-certified laboratories have guidelines for handling patient samples and reporting results. In rare cases, problems with sample labeling or handling may lead to incorrect results or an additional sample requirement if the sample is damaged or inaccurately submitted. Genetic tests are handled in a confidential manner. The person collecting my sample, and the genetic testing laboratory performing the test, will physically handle my sample. I have the right to know what will happen to any remaining sample from the genetic test. As part of the informed consent provided by the genetic testing laboratory (which is separate from this informed consent from AT-GC), the laboratory’s consent process should address whether I may choose to have my sample used for other purposes, such as research.
The cost of genetic testing at the laboratory depends on the test performed, and this is not the responsibility of AT-GC. Typically, the cost can range from no cost to a few hundred or several thousand dollars. Before testing, I may ask the genetic testing laboratory or my insurer about the cost of the test and whether it is covered by my insurance.
Genetic tests are not always covered by medical insurance, and I may need to pay some or all of the cost. I understand that this information is outside the scope of AT-GC, and must be addressed with my insurance company and/or genetic testing laboratory directly.
I understand that AT-GC strongly recommends that I provide my genetic consultation information to my regular care team. AT-GC is happy to share this information at my request. A genetic evaluation may sometimes reveal confirmation of, or establishment of, an individual’s risk for a genetic condition(s). It is important that I discuss my genetic test results with my genetic counselor or health care provider so that I am informed about what the results mean.
Some extensive tests look for genetic changes across a person’s genetic makeup. When this type of testing is done, there is a possibility that it might reveal a risk for a genetic condition that is unrelated to the original reason for testing. How a laboratory reports secondary findings depends on a number of factors including laboratory policies, whether knowing the result will change a person’s medical care, and patient preference. I understand that it is important to talk with a laboratory representative or health care provider to discuss how I want any potential secondary findings handled if this information is not covered in the laboratory’s informed consent information.
Genetic tests are often a valuable tool, but sometimes do not provide a definite answer. It is important that I ask my genetic counselor and/or provider questions that I have regarding my genetic testing. Genetic counselors are trained professionals that are able to take into consideration an individual’s personal health and family histories in conjunction with complex genetic information to interpret these results in accordance with national standards, guidelines, and recommendations that may exist for the known genetic information. Most often, results can be classified as negative, variant, or positive.
b. A variant result means that a test detected a change in the genetic material, but that this particular finding is ambiguous and does not provide useful or conclusive information at this point in time. Everyone has some harmless gene changes (i.e., polymorphisms). Variants can be polymorphisms, or they can be harmful (i.e., deleterious) mutations. Variant results indicate that the laboratory does not have enough information to determine whether or not the change is associated with a genetic condition or its risks and medical management. As more becomes known about specific genetic variants, laboratories may eventually reclassify variant results as negative or positive. Individuals with variant results should contact their provider periodically to see if reclassification has taken place or whether any more information is available. It is important to note that variants are more common with larger panels and extensive testing than with targeted testing, with variant frequency estimated in these cases to be ~30%. It is not recommended that variant results alone change medical management.
c. A positive test result means that a laboratory found a change in the genetic material that is structurally different than what was expected to be seen and is known to lead to or potentially lead to health effects. This genetic mutation can serve as a confirmation for a diagnosis or can indicate an increased risk of developing a specific genetic condition in one’s lifetime. A positive result may have implications for further testing. Preventative measures, treatments, or medical recommendations may or may not exist. It is important to note that only some genetic changes lead to symptoms, and for in people who do not have personal symptoms of the disease, such as is the case with predictive or presymptomatic testing for hereditary disease, a given individual’s exact risk for developing the condition, and the severity of the condition, is generally unknown. An example of a positive result that does not lead to genetic disease is a positive result related to an autosomal recessive trait (e.g., carrier testing). This type of result means that you have an increased chance of having a child with a specific genetic condition; however, in most cases, being a carrier does not increase your own chance of the condition. Other inheritance patterns also exist for genetic conditions and can be discussed by a qualified genetics professional. Genetic mutations can be passed down in families; therefore, positive results may have implications for family members. It is important that you discuss in detail any positive test results with a genetic counselor or another knowledgeable healthcare provider.
I understand that the evidence supporting medical recommendations for specific genes and results varies. In some cases, there is strong evidence to guide medical recommendations or guidelines. In other cases, there is no, or limited, evidence to guide medical recommendations. I understand that information regarding the testing methodologies, procedures, and processes are available through the genetic testing laboratory that performed my test, and that I may request this information for my review and the review of my healthcare provider.
I understand that in the case of certain positive results, specific risk-reduction options may be addressed by increased screening, chemoprevention, or, in some cases, prophylactic surgeries, with additional information dependent upon personal health and family history. AT-GC highly recommends that all patients undergo results genetic counseling with a genetic counselor or another qualified genetics professional, and especially those with positive, variant, or negative results with a personal or family history of the condition.
Testing in other relatives is complex may or may not be indicated, particularly for genes of moderate penetrance. Implications for family members may vary based on the gene(s) in question, and a range of possibilities exist.
The health care provider who ordered the test will receive the results and I may request these results from my provider. My medical record and test results are confidential.
This informed consent document was developed and compiled by Advanced Tele-Genetic Counseling. Nothing may be altered nor deleted to change the meaning of specific statements above or the intent of the informed consent process without the permission of AT-GC.
I have taken the time to read, or have read to me, the statements in this informed consent document regarding telehealth and to think about whether I would like to undergo a genetic consultation by AT-GC. I have been informed of the nature and purpose of genetic consultation and potential genetic testing, as well as the meaning of the possible test results, and I understand the information presented. I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction. I understand the contents of this consent document, including the risks, benefits, and practical alternatives described herein. I have been given the opportunity to discuss this document with my healthcare provider, or such assistants as may be designated, and to have this information explained to me. I also understand that I have the opportunity to discuss my decision with family and friends. I voluntarily agree to the information in this document, if and until I decide otherwise. Utilizing AT-GC’s services is entirely my choice. I may change my mind at a later time. I do not give up any of my legal rights by signing this consent document.
I hereby state that I have read, understood, and agree to the terms of this document. I give my informed consent to AT-GC telehealth consultations under the terms described herein. My consent was obtained prior to participation in the consultation. I may save a copy of the signed consent document for my records or request a physical copy, and the signed consent document will be electronically housed by AT-GC, should I need to access this information in the future. I voluntarily request AT-GC to perform genetic consultation in an attempt to determine the genetic risks for which I may be at increased risk.