Healthcare Professional Authorization Agreement
I certify that I have discussed with this patient the medical reasons for ordering this test. Inaddition, I have obtained from this patient all other consents that the laws of my state requirein performing genetic testing on patients. I further certify that this test I am ordering is medicallynecessary. The results of this test will be used in the medical management of this patient and/or for genetic counseling of this patient and his/her family member(s). I have provided geneticcounseling to the individual(s) listed above and explained the potential risks, benefits andlimitations of receiving incidental findings and answered all of their questions. I understandthat GeneSavvy may contact the patient to obtain required billing and processing information. Ialso authorize GeneSavvy to submit a letter of medical necessity on my behalf to assist patient in receiving insurance benefits for testing.
Whole-Exome Clinical Presentation Agreement
I understand that I will be contacted by a GeneSavvy Representative to discuss the above patient's current clinical presentations and clinical history of present illness (HPI). The results of the Whole-Exome testing will be filtered to show variants of significance association with current HPI.