Terms of Service & Privacy Statement
When you sign up for Genetic Medicine Clinic service you agree to our Terms of Service.
You are making important representations when you use our service. While they are all important, we would like to call your attention to three representations below:
Three Important Points You Agree to When Using Our Service:
- You are consenting to be our Patient. You should not change your health behaviors solely on the basis of our information but discuss your care with yoru Primary Care Provider . Keep in mind that genetic research is not comprehensive and the laboratory process may result in errors.
- You may learn information about yourself that you do not anticipate. Once you obtain your genetic information, the knowledge is irrevocable.
- Our Privacy Statement describes what personal information we collect from you, how we use and protect it, and your rights and choices. These “privacy highlights” provide an overview of some core components of our data handling practices. Please be sure to read our full privacy statement.
- Privacy Highlights
- We use information in general (i) to provide, analyze and improve our Services, (ii) as we reasonably believe is permitted by laws and regulations, including for marketing and advertising purposes, (iii) to protect the security and safety of our company, employees, customers as we reasonably believe permitted by laws and regulations, (iv) to comply with laws and regulations we are subject to.
CONSENT TO THE USE OF SENSITIVE INFORMATION
By agreeing to our Privacy Statement and Terms of Service, you consent to sensitive information, such as information about your health, Genetic Information, and Self-Reported Information such as racial and ethnic origin and sexual orientation (where you provide it) being used by us to:
- analyze and provide you with our Services;
- analyze and provide you with information about your Genetics;
- determine whether you would be suitable to take part in surveys, polls or questionnaires that we are conducting; and
- monitor and improve existing products or services that we offer or develop new products and services
We will not use your sensitive information without your consent unless: (i) the information has been anonymized or aggregated so that you cannot reasonably be identified as an individual; or (ii) a legal obligation requires us to use it in some way e.g. a court order requires us to disclose the information.
CONSENT TO THE TRANSFER OF YOUR PERSONAL INFORMATION
- By agreeing to our Privacy Statement and Terms of Service, you consent to the storing and processing of your personal information, including sensitive information, in the USA and countries outside of the country you live in. We use a range of measures to safeguard information but these countries may have laws that are different from those of your country of residence. You also consent to your personal information, including sensitive information, being transferred in the event of a business transition such as a merger, acquisition by another company, or other transaction or proceeding. In such a case, your information would be used as set out in any pre-existing Privacy Statement.
- We will not sell, lease, or rent your individual-level information (i.e., information about a single individual’s genotypes, diseases or other traits/characteristics) to any third party or to a third party for research purposes without your explicit consent.
- We give you the ability to share information with other individuals. You will always need to take a positive action to share your information, for example, there is an opt-in requirement before we share your information with potential relative matches.
- You may independently decide to disclose your information to friends and/or family members, doctors, health care professionals, or other individuals outside our Services, including through third party services such as social networks and third-party apps that connect to our website and mobile apps through our application programming interface (“API”); always review the privacy policies of third-party apps and services before sharing your information.
- We may share anonymized and aggregate information with third parties; anonymized and aggregate information is any information that has been stripped of your name and contact information and aggregated with information of others or anonymized so that you cannot reasonably be identified as an individual.
- We will use your information and share it with third parties for scientific research purposes only if you sign a Consent Document. Note that we will disclose your individual-level information only if we obtain additional explicit consent from you.
- There may be some consequences of using Genetic Medicine Services that you haven’t thought of, you should read our guideof the surprising things you may find out from using the service before submitting your saliva sample and personal information.
- If you have any questions about our privacy practices, please email us at email@example.com or send a letter to the address provided at the bottom of our full privacy statement.
Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Genetic Medicine Clinic to use and disclose
protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
(The Notice of Privacy Practices provided by Genetic Medicine Clinic describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent.
Genetic Medicine Clinic reserves the right to revise its Notice of Privacy Practices
at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Genetic Medicine Clinic 7550 W University Suite B, Gainesville, FL 32607.
With this consent, Genetic Medicine Clinic may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Genetic Medicine Clinic may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Genetic Medicine Clinic may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Genetic Medicine Clinic restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Genetic Medicine Clinic to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Genetic Medicine Clinic may decline to provide treatment to me.
CONSENT AND AUTHORIZATION FOR TREATMENT
SECTION A: NOTICE OF LIMITED LIABILITY
The care provided by the Genetic Medicine Clinic, is subject to the provisions of s. 76S.2S, Florida Statutes, which limits recovery for negligent acts and omissions as set forth therein.
SECTION B: CONSENT AND AUTHORIZATION
- Authorization for Routine Diagnostic Procedure and Medical Treatment: I hereby consent to such diagnostic procedures, hospital care, and medical treatment which in the judgment of my health care provider may be considered necessary or advisable while a patient at a Genetic Medicine Clinic Physicians facility. I recognize that the Genetic Medicine Clinic Physicians are often accompanied by students and that my treatment and care will be observed and in some instances aided by students under appropriate supervision. I understand that my physician may access my medical information from a variety of sources, including information about my medication use that comes from proprietary sources. I consent to the Genetic Medicine Clinic Physicians video-taping and taking photographs of me in the course of and related to my treatment and to their use of such videos, photographs and my medical data for educational purposes.
- Authorization to Use/Retain/Preserve Tissue: I hereby authorize The Genetic Medicine Clinic Physicians to retain, preserve and use for scientific, educational or research purpose, or dispose of as they might deem fit, any specimens or tissues taken from my body during hospital or clinic visits. If applicable, this authorization is also given on behalf of my unborn child during this period of treatment and/or examination.
III. Assignment of Benefits: I hereby assign to the Genetic Medicine Clinic Physicians payment from all third party payors* with whom I have coverage or from whom benefits are or may become payable to me, for the charges of hospital and health care services I receive for, related to, or connected with this admission or treatment (past, present, or future). I agree to be personally responsible for payment of any hospital or health care services that are not covered by my third party payors”, including, but not limited to, non-covered or out-of-network services, deductibles, co-insurance, and/or co-payments.
- Release of Medical Information by the Genetic Medicine Clinic Physicians: By signing in the space below as Patient/Guardian, I hereby authorize the Genetic Medicine Clinic Physicians providing services during my outpatient clinical care, to release information from and/or copies of my medical records (including information relating to psychiatric and/or psychological care, alcohol and/or substance abuse, and HIV tests), and other information as may be required for my medical care and to secure payment for charges incurred by me or on my behalf, to: any Genetic Medicine Clinic Physicians facility or affiliated provider, the Tumor Registry, my physician, my referring physician, the Guarantor on my accounts, insurance companies for which I have assigned benefits for my treatment and care, or to any sponsors that the Genetic Medicine Clinic Physicians may later obtain to contribute payment for my treatment and care. I also authorize release of any information to any and all regulatory and/or accrediting organizations as necessary to the outpatient clinics to maintain its licensure and accredited status. In addition, I authorize release of any information to county, state or federal public health agencies, as required by law. I further authorize the Department of Child and Family Services and/or the Social Security Administration to release any confidential case information in my application for government assistance, which is requested by the Genetic Medicine Clinic Physicians.
- Risk Management and Dispute Resolution: I agree that my patient information (including, but not limited to, my medical records, billing information, and information I disclose to a health care provider in the course of my care and treatment) may at any time be used by and disclosed to employees, officers, agents, and legal representatives of the Genetic Medicine Clinic, or both, for purposes of risk management, and formal and informal dispute resolution processes (including, but not limited to, litigation and mediation) involving one or both entities.
- Agreement to Mediate: In accepting care at a Genetic Medicine Clinic facility, I agree that before I file any lawsuit against the Genetic Medicine Clinic or any of its facilities, employees or agents, and/or the Genetic Medicine Clinic Board of Trustees, arising out of the care provided to me by physicians, nurses, and other healthcare providers, I will first attempt to resolve my claim through confidential mediation. Mediation is a process through which a neutral third party person who has been certified to be a mediator tries to help settle claims. Genetic Medicine Clinic will pay the cost of the mediator. I further agree that any mediation must take place in the State of Florida and in the county where my treatment was rendered, unless all parties agree otherwise. This agreement is binding on me and any entity or individual making a claim on my behalf. This agreement does not waive my right to file a lawsuit if the mediation process fails to resolve my claim. I understand that lawsuits must be filed within a certain period and that the lime for me to file a lawsuit is not extended as a result of my participation in mediation.
- Guarantor Agreement: By signing in the space below as Patient/Guardian or Guarantor, or as Patients/Guardians Spouse or Guarantors Spouse, I hereby agree that all charges connected with the treatment, not covered by any insurance, program, sponsorship or other third party coverage I may have, are due and payable by me at the lime of the visit or discontinuation of treatment. If the insurance information I have provided is not active at the time of service or if the services provided are not covered by my insurance company, I will be responsible for any balance due at the time of service. The charges I agree to pay are Genetic Medicine Clinic set fees, as modified by any applicable contract Genetic Medicine Clinic may have with an insurer, which are available for inspection upon request and incorporated herein by reference. I understand that billing statements will be sent to the patient for whom the services have been rendered, but as guarantor, I am responsible for payment. I hereby acknowledge that, unless the Genetic Medicine Clinic Physicians and my insurance company or third party carrier have agreed that I will not be billed, if the Genetic Medicine Clinic Physicians has agreed to bill my insurance or other Third party carrier it has agreed to do so as a courtesy and that the Genetic Medicine Clinic Physicians has the right to demand payment in full from client at any time prior to full payment from any insurance carrier. If an overdue account is referred by collections, I agree to pay the attorney’s fees, court costs and/or collection agency fees associated with the collection process. I specifically waive any exemption of wages from garnishment, which might be available by law, and agree that my wages can be garnished in the event a judgment is entered against me for collection of the outpatient clinic charges 1 have agreed to pay.
- Agreement to Pay for Professional Component of Pathology Services: When a specimen of my blood, urine, stool, or similar material is tested, the testing will be performed under the supervision of the pathologist who directs the laboratory. The pathologist may not perform the test or personally review its results. however, the pathologist is responsible for supervising the laboratory. I will receive a bill from the pathologist for these supervisory services for each test even if the pathologist did not personally perform the test or review its results. By signing this document, I agree to be responsible for the pathologist’s bill to the extent that payment is not provided by my Third Party Payor.
“Third Party Payors include, but are not limited to, coverage available from: Medicare, Medicaid, Tri-care, or governmental programs; health, accident, automobile, or other insurance; worker’s compensation, (Medicaid, Medicare), self-insured employers; and any sponsors who may contribute payment for services.
Refund Policy on Clinical Services
At Genetic Medicine Clinic we value your business, and strive to exceed your expectations! Due to the nature of our clinical services we do not offer any refunds or returns. With that being said, if you are unsatisfied in any way please let us know so we can ensure your experience is positive!
If you have made a payment to your account and it has been found that an overpayment was made, Genetic Medicine Clinic will issue a refund to the original credit/debit card used to make the initial payment. All credit requests must be made by contacting our billing department or email to firstname.lastname@example.org
Refunds may result from the following:
- Duplicate Payment Received
- Additional payments issued by the insurance carrier
Please allow 7 days for the processing of all refunds to be issued.
Genetic Testing or Laboratory Services Refund Policy
If you have purchased genetic testing or laboratory testing through us, you have up to 2 months to provide your sample to the laboratory for testing. If the samples are not received and testing is not initiated you will be refunded your purchase price minus a $50 fee or a $50 reactivation will apply to reactive the testing process.
If the testing is canceled prior to initiation of testing services, a refund will be given less a $50 administration fee. If testing services are canceled after testing kits have been purchased/shipped than a 50% refund will be applied to the testing kit minus the shipping fee.
Once testing has begun on a sample, no refunds will be issued. A sample processing fee may be assessed for the amount of sample processing that was initiated prior the cancellation.