TELEHEALTH PATIENT INFORMED CONSENT FORM


Informed Consent

I, the undersigned, having been fully informed as set forth below, hereby authorize and give my informed consent to NxGen MDx, LLC and its designated genetic counselor providers, who may be provided through NxGen by a third party contracting with NxGen (“NxGen”), for the provision of genetic counseling services through the form of telehealth.

Telehealth Services

I understand that NxGen and its designated genetic counselor providers offer genetic counseling services, including the discussion of genetic testing and the opportunity to request genetic testing, if applicable. NxGen offers these services to patients like me by way of phone consultations through the use of “telehealth.” Telehealth, in this context, means the provision of health services from a distance, where the patient and the health services provider are not in each other’s sight and presence, and may include the provision of health care services by means of audio, video, or other telecommunications or electronic technology, as well as the transmission of patient-specific information, clinical information, or documents by means of audio, video, or other telecommunications or electronic technology.

I understand that the provision of genetic counseling services via telehealth offers me certain benefits, including broader access to such services and the availability of otherwise difficult to obtain expertise regarding genetic counseling.

I also understand that the provision of genetic counseling services via telehealth exposes me to certain risks, including difficulty in integration of health care services among multiple providers across digital platforms, potential access by unauthorized persons of my protected health information despite security measures and encryption, other potential breaches of confidentiality associated with the telehealth, and different health record access standards.

I agree that I have been given ample time and opportunity to ask any and all questions regarding the use of telehealth and have received all requested information and answers to questions that I require.

I understand that there are risks to receiving health services via telehealth and I voluntarily accept those risks.

I further agree that I have consulted with my local physician and my local physician has agreed to receive the genetic test results, if applicable, and/or the genetic counseling consultation notes produced by NxGen or its designated genetic counselor, and to be responsible for and direct my follow-up care. I acknowledge that NxGen will send my genetic test results, if applicable, and/or my applicable genetic counseling consultation notes to the physician that I designate to be responsible for and direct my follow-up care.

I acknowledge that I have the right at any time to withhold or withdraw my consent to receive health services via telehealth, without affecting my right to receive future health services from NxGen. If I withdraw such consent after having first given it, I will do so in a writing delivered to NxGen.

I understand that the laws that protect the confidentiality of my health information apply to telehealth. My protected health information will not be disclosed without my consent, except as permitted by law.

I understand that I have the right to inspect and obtain copies of my health records, including those health records related to health services provided to me by means of telehealth. Any such requests to inspect and obtain such copies will be made in accordance with NxGen’s standard policies and procedures.

I will not record, stream, or capture any of my telehealth communications with my genetic counselor.

I understand that I am not required to obtain genetic counseling services via telehealth, and I am free to seek such services through means other than telehealth.

I understand that by signing below, and/or entering in the below information and checking the following box electronically, I agree to receive the genetic counseling services described above by means of telehealth under the terms of this consent. I fully understand this consent and am signing it voluntarily.

Consent Form