Patient pre-authorization form

Patient pre-authorization form

for Second Opinion Service supported by Genomate
A request may be submitted on your behalf by a family member or representative for a Second Opinion Service supported by Genomate.

Before any request is submitted or any medical information is shared, we require your direct confirmation of your identity, your authorization for another person to act on your behalf, and your consent to the terms of the service.
Patient details
Name*

First NameLast Name
Date of birth*

MonthDayYear
Email*
example@example.com
Authorized Representative details
Name*

First NameLast Name
Email*
example@example.com
Please ensure that all information provided is accurate.

Please note that a request cannot be submitted and the service cannot proceed unless this form is completed by you, the patient.

For legal reasons related to the Second Opinion consultation, you must be physically located in the State of Texas at the time of the virtual consultation.

Type a question
I understand that this Second Opinion consultation will be provided using telehealth technologies, which may include video conferencing, audio communication, secure electronic messaging, and electronic document review and signing. 

I understand that Genomate Health Inc. provides administrative and technical support for this service and does not provide medical care, and that all medical services, opinions, and clinical decisions are provided solely by an independent licensed consulting healthcare professional.

I confirm that I will be physically located in a U.S. state where this service is offered at the time of the consultation, as required by applicable medical licensing and telehealth laws, and I understand that the consultation cannot proceed if this requirement is not met.

I understand that telehealth involves the electronic transmission of medical information and that there are potential risks, including technical failures, interruptions, or unauthorized access despite having reasonable security measures in place.

I understand that telehealth services may not be equivalent to an in-person medical evaluation and that no physical examination will be performed. I understand that the consulting healthcare professional may determine that telehealth is not appropriate in all circumstances and may recommend follow-up with my treating physician or in-person care. 

I understand that the consultation may, but will not necessarily, be audio and/or video recorded for documentation and quality purposes, and by signing this form I consent to such recording if it occurs.

I understand that this service is not intended for medical emergencies or urgent care situations, and that in the event of an emergency I should seek immediate medical attention from my treating physician or local emergency services. 

I understand that I may withdraw my consent to receive healthcare services via telehealth at any time by notifying Genomate Health Inc. or the consulting healthcare professional.
Second Opinion Service Consent & Limitations
I understand that this service provides an independent second medical opinion based on the medical information and documents that I submit. I understand that a Second Opinion is advisory in nature and does not replace, supersede, or substitute the care, diagnosis, or treatment provided by my treating physician or healthcare team.

I understand that this service establishes a limited consulting physician–patient relationship solely for the purpose of providing this Second Opinion and any associated consultation, and does not include ongoing care, treatment, or follow-up, unless otherwise expressly agreed in writing.

I understand that treatment options, drugs, or therapeutic strategies discussed as part of this Second Opinion are provided for informational purposes only and do not constitute a prescription or directive for treatment. I understand that this service does not guarantee any specific outcome, including treatment response, disease progression, survival, or the absence of adverse events, and that all treatment decisions remain the responsibility of my treating healthcare team.

I understand that, in forming this second medical opinion, the consulting healthcare professional may use clinical decision support tools, including Genomate®, a clinical decision support software for precision oncology as described in Section 520(o) of the Federal Food, Drug, and Cosmetic Act (FDCA). I understand that such tools are intended to support, but not replace, the healthcare professional’s independent clinical judgment, and that any opinions, interpretations, or recommendations provided as part of this service are solely those of the consulting healthcare professional, based on their professional assessment and my individual clinical circumstances.

I understand that this Second Opinion is based solely on the review of medical records and information provided and does not include a physical examination or in-person evaluation. As a result, the consulting healthcare professional may not have access to information that would otherwise be obtained through an in-person assessment, which may affect the completeness or accuracy of the opinion provided. I understand and accept these limitations and the associated risks inherent in a record-based, remote Second Opinion.

I understand that the consulting healthcare professional provides this opinion within the scope of their medical licensure applicable to my location.
HIPAA Authorization & Privacy Acknowledgment
I authorize Genomate Health Inc. and the consulting healthcare professional to collect, use, and disclose my personal information and protected health information for the purpose of providing this Second Opinion Service. This may include, but is not limited to, information relating to my medical history, prior diagnoses, pathology reports, molecular and genetic profiling results (including NGS and other biomarker testing), imaging reports, treatment history, medications, laboratory results, and any consultation reports or communications generated as part of this service. This authorization includes the collection, use, and disclosure of genetic information, including molecular and genomic test results, for the purpose of providing this Second Opinion Service, in accordance with applicable law.

At my direction, information relating to this service may also be shared with the Support person, who initiated the request on my behalf, to the extent necessary for coordination, scheduling, payment, receipt of the report, and related communications, as authorized by me in this form and permitted by applicable law.

I understand that my health information may be shared with the consulting healthcare professional, my treating healthcare providers, and any support person I have authorized, as well as with administrative or technical service providers involved in delivering this service, as necessary and in accordance with the Privacy Notice.

I acknowledge that I have read and understand the Privacy Notice (www.genomate.health/legal/second-opinion-service-privacy-notice) and the Terms and Conditions (https://www.genomate.health/legal/second-opinion-service-terms-conditions), and how my personal and health information will be processed in accordance with applicable laws. I understand that I may revoke this authorization at any time by contacting Genomate Health Inc. at privacy@genomate.health, except to the extent that action has already been taken in reliance on it. Unless revoked earlier, this authorization will remain in effect until completion of the Second Opinion Service.

You acknowledge that any information submitted on your behalf by an authorized representative is provided under your authorization. You are responsible for ensuring that such information is accurate and complete, and for notifying us of any inaccuracies.

I understand that this authorization is required to provide the Second Opinion Service, and that the service cannot be delivered without it.
Patient Signature*

By signing above, I confirm that I am the patient identified above and that I authorize the Authorized Representative to submit this request and to act on my behalf in connection with this Second Opinion service, including communicating with Genomate Health Inc. and the consulting healthcare professional, participating in any consultation or related interactions, and receiving information and the final report, as permitted by applicable law. I consent to the Second Opinion consultation and related services as described above and in the applicable Terms and Privacy Notice.
Should be Empty:

Patient pre-authorization form

Patient details

Authorized Representative details