Patient Authorization, Acknowledgement and Release
I authorize Peak Xpression, its agents and/or contractors to test my sample (or the sample of the dependent(s) listed). My health care practitioner and/or Peak Xpression representatives have satisfactorily explained the benefits, risks and limits of this testing. My name entered below acts as my signature and constitutes my understanding of the preceding information. I have fully reviewed this form, understand and agree to its terms. I consent to buccal specimen collection for myself and/or any listed dependent(s) for DNA testing by Peak Xpression, its agents and contractors. Information on genomic variations is based on the latest information found by often decades of studies on usually thousands of individuals. I understand Peak Xpression representatives are not responsible for medical or other decisions made based on testing results. I certify the information provided in this application is true and accurate. I understand this test is a whole or partial genome sequencing test, depending on which level of coverage I have selected, to identify genetic variations in my DNA. These variations may be used to help inform my clinician(s) as to the best treatment for the condition(s) for which I seek care. I acknowledge and agree that future developments may expand the knowledge available regarding the role of particular genes. I authorize Peak Xpression to release additional information on my results to me should it become available and if I authorize this requested. I also understand my financial responsibility would include any additional testing and reporting that I request. I have been informed that all parties involved in this testing will adhere to the Genetic Information Nondiscrimination Act (GINA) of 2008 which prohibits discrimination in health coverage and employment based on genetic information. DNA test results are not intended to be used as the only tool for treatment management decisions.
Patient Consent
I consent to the collection of specimens for myself or any listed dependent for the purpose of DNA testing by Peak Xpression, its agents and/or contractors to provide information on my genetic code. I understand Peak Xpression, its representatives and/or contractors are not responsible for any medical or other decisions based on the results of the DNA test results. I hereby release and hold Peak Xpression, its employees and contractors harmless from any liability arising from such decisions, including from any course of treatment chosen using the test results. If I choose to share my genetic or other personal information with third parties - whether intentionally or inadvertently - I agree to hold Peak Xpression, its employees and contractors harmless from any and all liability arising from such disclosure or use of my genetic information or other personal data. I agree I have the authority under the laws of state or jurisdiction in which I reside, to provide this release.
Financial Responsibility - I understand my HSA/FSA account may pay for services, but I need to contact my insurance provider to submit reimbursement for payment, if applicable.
