GeneSight^® Patient Consent Form

By signing below, you agree to the following:

Purpose and process

• I give consent for GeneSight testing. I understand the GeneSight panels will test for genetic variants related to the metabolism or action of various mental health medications.
• I understand this test is intended to be used by my clinician to assist in medication treatment decision-making. I will address with my clinician any concerns I have about medication changes as a result of this test.
• Once my test results are provided, Myriad Neuroscience removes all personal identifiers on my samples and may use the sample and information derived from the sample for purposes of test validation, education, and research and development of new products. Patient samples, including samples from New York, shall be destroyed at the end of the testing process or not more than 60 days after the sample collection date.
• By providing my email and mobile number below, I consent to receiving communication from Myriad Neuroscience (including SMS messages). I understand the risks of communication in this manner and that Myriad Neuroscience cannot guarantee the security and confidentiality of such communication. I understand I may revoke this consent by contacting Myriad Neuroscience.

Coverage and cost

• If I am covered by insurance, I authorize Myriad Neuroscience to give my designated insurance carrier, health plan, or third-party administrator the information necessary or reasonably requested for reimbursement. I understand Myriad Neuroscience can appeal to my health insurance plan if the service is either partially paid or denied, and release all relevant medical records, only for the purpose of health insurance plan coverage. I understand that my test may not be covered by my insurance if deemed medically unnecessary. In that event, I may receive a bill from Myriad Neuroscience.
• I understand that $330 is an estimate of a typical patient financial responsibility for the GeneSight test. I understand that Myriad Neuroscience will contact me prior to processing my test if my total financial responsibility could be more than $330.
• I authorize that direct benefits under this claim be paid directly to Myriad Neuroscience. If I receive payment directly from my health insurance plan, I will promptly send the payment to Myriad Neuroscience.
• I authorize Myriad Neuroscience to complete a soft credit inquiry on me, which will not impact my credit score, and agree that that information may be used to qualify me for financial assistance or other billing programs.

I agree that I have read and understand the terms listed above. I understand that Myriad Neuroscience will send me a statement for any balance due after my health insurance plan has processed the claim. I understand and agree that I will pay the full amount of this statement to Myriad Neuroscience within 30 days of receiving the statement. If there is a balance due, I understand that Myriad Neuroscience will provide applicable patient financial assistance program information. If I qualify for financial assistance, I agree to provide Myriad Neuroscience with any additional information or documentation that may be needed to confirm my qualification for the financial assistance program.

By signing below I attest that I am the patient or someone who is designated and authorized to sign and provide consent on behalf of the patient for healthcare and financial matters. If the healthcare provider/facility allows for a verbal consent for testing (including financial responsibility), please provide in the spaces below the printed name of the authorized person giving consent and the name of the representative verifying consent. Identify each name provided.