Informed Consent Compliance
for Germline Genetic Testing


* Indicates a required field.

Account Name * Questions about this form? Please contact 866-MY-QUEST.
Country *  
Address 1 *  
Address 2  
City *  
State  
Zip Code *  
Phone *
Account Number * Lab *  

Physician Coverage
I am signing on behalf of all physicians using this account.
I am signing as an individual practitioner with NPI
 

Test Coverage
Blanket - Covers all tests ordered.
Refuse Blanket - I prefer to sign an individual informed consent compliance form for each test ordered.
 

Office Type
Physician Practice
Hospital / Laboratory


This attestation remains in effect until an updated form is submitted.




If you prefer, you can download a PDF of a blanket or patient consent to fill out, sign and fax back to 844-595-4288.



Background

Some state laws require that individuals (or their authorized representative) provide written informed consent to the physician performing germline genetic testing and/or releasing test results.

The individual (or authorized person) must sign and date a consent form that includes:

 
  • Statement of test purpose and description.
  • Statement that prior to testing, the physician ordering the test discussed with the individual the reliability of positive/negative test results and the level of certainty that a positive result for the disease or condition serves as a predictor of such disease.
  • Statement that the physician informed the individual about availability and importance of further testing, physician consultation and genetic counseling, and provided written information identifying a genetic counselor or medical geneticist.
  • General description of each disease or condition for which a test is ordered.
  • The name of the person or persons to whom the test results may be disclosed.


Physician Attestation of Informed Consent (PAIC)