|________(insurer name) ________||____________________________________|
|(name of person being tested)|
|______________________________||(name of person giving consent, if different)|
Unless specifically authorized or required by law, you cannot be required to take a genetic test without your specific, written, informed, prior consent or the consent of a person authorized to consent for you.
To evaluate your eligibility for insurance coverage, ______(insurer name) ______ requests that you consent to the following genetic test(s) to be performed for the following reason(s):
|Test name or type: ____________________||Test name or type: ____________________|
|Reason(s) for test: ____________________||Reason(s) for test: ____________________|
Genetic Test means an analysis of an individual's DNA, gene products or chromosomes that indicates a propensity for or susceptibility to illness, disease, impairment or other disorders, whether physical or mental or that demonstrates genetic or chromosomal damage due to environmental factors, or carrier status for disease or disorder. A blood, saliva, or other test does not constitute a genetic test unless performed specifically to analyze your DNA, gene products or chromosomes.
The results of this genetic test are privileged and confidential and may not be released to any party without your expressed consent.
CONSENT TO GENETIC TEST AND
CONSENT TO RELEASE OF GENETIC TEST RESULTS
I have read and understand this Notice and Consent Form. I voluntarily consent for myself or the proposed insured to the genetic test(s) for the reason(s) specified above and understand that I have a right to request and receive a copy of this form. I give my expressed consent to ____(insurer name)'s____ release of the results of the genetic test(s): (a) to its affiliates, employees, contractors, reinsurers, or assigns, (b) in response to a court or administrative order, subpoena or warrant, or (c) to an insurance regulatory authority A photocopy of this form will be as valid as the original.
___ I want to receive the results of my genetic test.
___ I authorize the additional release of the results of my genetic test to the person named below:
|Signature of Person to be||Name (your additional release authorization)|
|Tested or Parent/Guardian||__________________________________________|