I am a qualified healthcare provider who is legally authorized to order this test. I am the treating practitioner, and this testing is medically necessary and appropriate for this patient and the results will be used to determine the patient’s treatment plan;

I have obtained the patient’s informed consent to perform this test as documented on a signed consent form that complies with applicable law;

I have received the patient’s consent for your laboratory to release test results and submit all necessary information to insurance for payment and genetic counseling if needed; and

I understand this testing will be based on the most updated requisition and test description available. I further confirm the patient has been appropriately counseled and understands the risks, benefits, and limitations of this genetic testing and the implications of the results.