Please complete this form to refer your patient for FTD genetic counseling and testing. These services are provided at no cost to the patient. For questions, please contact: (888) 959-2028     

                                        

FTD Genetic Counseling and Testing Referral

Patient Name*
Date of Birth*
Please confirm the patient meets eligibility criteria for the program*
Address
Language Interpreter Needed?

Provider Information

Referring Provider*
Provider's Address*
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Patient Consent

Is the patient able to sign e-consent for genetic counseling?


General Consent & Consent for Use and Disclosure of Protected Health Information 


General Consent: I hereby give consent to the genetic counselors and physician geneticists employed by InformedDNA (IDNA) to perform genetic counseling services as might be requested by my treating provider or me.  Such genetic counseling may include, but is not limited to, review of personal and family medical history, risk assessment, review of genetic test results and medical management options.  I acknowledge and agree that this consent will be applicable to all genetic counseling sessions performed by IDNA genetic counselors and physician geneticists.

Consent for Use and Disclosure: 

I hereby give my consent for IDNA to use and disclose protected health information (PHI), including genetic information, about me and/or my child to carry out treatment (including genetic counseling services), payment and health care operations (TPO). (the Notice of Privacy Practices provided by IDNA describes such uses and disclosures more completely).

I understand that this means IDNA may disclose PHI to discuss my case with my referring provider, the genetic testing laboratory or any health care professional that I or my referring provider designates, in order to ensure continuity of care.  PHI generally refers to demographic information, personal and family medical history, other genetic information and test and laboratory results.  I also understand that IDNA may also de-identify my data and utilize it for research purposes or disclose it to third parties, including external laboratories or other entities that IDNA partners with that may use the data for research, operations, product development and any other purpose permitted by applicable privacy laws.  In such cases, my data will be de-identified, so that no information that is disclosed can be used to identify me and it will no longer be PHI.  I understand that I may also be contacted by IDNA about research opportunities or studies I might be interested in, if it is determined that I might be eligible for such studies.

I have the right to review the Notice of Privacy Practices (NPP) prior to signing this consent.  I understand that IDNA reserves the right to revise its NPP at any time and that a revised NPP may be obtained by forwarding a written request to the Compliance Officer, 877 Executive Center Drive W, Suite 306, St. Petersburg, FL 33702 or by visiting the InformedDNA website: informeddna.com.  I hereby acknowledge that I received a copy of IDNA’s Summary of Notice of Privacy Practices.

I have the right to request that IDNA restrict how it uses or discloses my PHI to carry out TPO.  I understand that IDNA is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I may revoke my consent in writing except to the extent that IDNA has already made disclosures in reliance upon my prior consent.  I understand that if I do not sign this consent, or later revoke it, IDNA may decline to provide genetic counseling services to me until this form is completed.


By signing below, I am providing my written consent to the procedures and uses and disclosures of my information discussed above and understand that it is valid for five years unless revoked in writing by me before that time.

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