Kean Health & DNAvisit Physician-of-Record Informed Consent
BY CLICKING “I ACKNOWLEDGE...,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT CLICK “I ACKNOWLEDGE...”, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
I agree to receive the services provided by DNAFeed Inc (DNAvisit), and certain affiliated professional entities (collectively, “DNAvisit”, “we” or “us”) relating to oversight of laboratory tests (“Tests”), including, without limitation, review of Test requests, receipt of Test results (“Results”), genetic counselor outreach, any customer support or counseling and any other related services provided by DNAvisit or its service providers and partners. (the “Services”)
I agree to the following:
• I confirm that I am at least 18 years old and that I am providing the sample for the Test.
• I understand that providing correct information is important. The information I have provided in connection with Test and the DNAvisit Services is correct to the best of my knowledge. I will not hold DNAvisit or its healthcare providers responsible for any errors or omissions that I may have made in providing such information.
• I certify that I am a U.S resident and physically present in the state of residence that I provided or other state of which I have notified DNAvisit.
• I have a right to talk to a healthcare provider about the test and/or my results. Genetic counseling may be available to help understand what the results mean for me and my family members.
• I understand that the information I have submitted will be reviewed by healthcare providers affiliated with DNAvisit.
• I understand that before my request for the test is approved, the DNAvisit clinical team, including a physician will evaluate my personal and family history information to determine if the Test is appropriate.
• I am responsible for forwarding any results to my primary care or other personal physician and for initiating follow-up with such physician for care, diagnosis, or medical treatment.
• I will not make medical decisions without consulting a healthcare provider or disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of DNAvisit Services.
• I understand that testing is voluntary and that I may withdraw my consent to the DNAvisit Services by contacting DNAvisit's Genetics Team by calling (650) 785-2076.
• I have had the opportunity to ask questions regarding the Test(s) and seek genetic counseling.
• All my questions were answered to my satisfaction and I understand the purpose of the Test(s).
• I have been provided with sufficient information regarding the Test. I have had the opportunity to discuss with a provider and I understand the reliability of a positive or negative result from the Test and the level of certainty of a positive result as a predictor of the disease or condition being tested for.
I understand that if I have any questions before or after my Test, I can contact DNAvisit's Clinical Team by calling (650) 785-2076.
- I understand that DNAvisit Services are delivered by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means, including the electronic transmission of personal health information. I also understand that:
- A DNAvisit physician will determine whether or not Test(s) and DNAvisit Services are appropriate for me.
- I have the right to withdraw my consent to the use of telehealth services by contacting the DNAvisit’s Clinical Team by calling (650) 785-2076.
- I may need to see a health care provider in-person for diagnosis, treatment and care.
- There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties.
- There are alternative services, such as visiting a primary care provider; however, I choose to proceed with the DNAvisit Services at this time.
I authorize DNAvisit to use the email address and phone number I provided in connection with my registration for the Test(s) (or that I updated by contacting DNAvisit's Clinical Team as described below) to contact me in connection with the DNAvisit Services, including, without limitation, initial outreach and post-test genetic counseling. I am responsible for contacting DNAvisit's Clinical Team by calling (650) 785-2076 to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the DNAvisit Services.
I specifically authorize the transfer and release of my information, including my laboratory test results and other health information, submitted by me or about me in connection with the DNAvisit Services, to, between and among myself and the following individuals, organizations and their representatives: (a) the applicable laboratory and its affiliates, their staff and agents; (b) DNAvisit and its affiliates, and their staff, agents, and health care providers, including physicians, and genetic counselors, and (c) laboratory and (d) certain providers for the purposes herein, to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing and approving a laboratory request; reviewing, processing and delivering the laboratory test value(s)/result(s) and genetic counseling), and as required or permitted by law.
I understand that I have a right to receive a copy of the above data disclosure authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization. This authorization will expire ten (10) years from the date of signature. My written revocation must be submitted to DNAvisit’s
General Counsel at:
Attn: General Counsel
10210 Campus Point Dr Suite 150 San Diego, CA 92121
DNAvisit does not provide any medical services for emergencies or urgent situations. If you are experiencing a medical emergency, please immediately call 911 immediately.
Your use of the Services is subject to any additional terms and policies, such as our Notice of Privacy Practices and any consents, of which we provide notice to you.
By using the Services, you acknowledge that you have read, understood and agree to be legally bound by and comply with these Terms, the Notice of Privacy Practices, and any and all additional terms and policies.
1. Changes to our Terms. We reserve the right to modify or amend these Terms, in whole or in part, at any time, and for any reason, in our sole discretion, with or without liability to you or any third party. All changes to these Terms will be effective immediately upon their posting to this webpage. We will notify you of material changes to these Terms by conspicuously posting the changes on the laboratory website. Continued use of the Services after the effective date of such modified Terms will indicate your acknowledgement and agreement to be bound by the modified Terms. You are expected to check this page from time to time so you are aware of any changes, as they are binding on you. Each version of our Terms will be prominently marked with an effective date at the top of this page. If any of the provisions of these Terms are not acceptable to you, your sole and exclusive remedy is to discontinue your use of the Services.
2. DNAvisit Services. DNAvisit does not provide medical advice and the Services are provided solely for informational purposes, and do not constitute treatment or diagnosis of any condition, disease or illness. Services do not replace your existing relationships with your primary care or family physician or other health care providers. You are solely responsible for forwarding any Results to your primary care or family physician and for initiating follow up with such physician for care, diagnosis or medical treatments. DNAvisit will not forward your Results to your family physician. You should not make medical decisions without consulting with a physician. Do not disregard medical advice from your healthcare provider or delay seeking such advice based on the information obtained as a result of your use of the Services. The Services are not intended to make a medical necessity determination.
By accepting the Terms, you understand that DNAvisit may send you messages, reports and emails regarding the Services, Tests, Results, and/or any personal or health information you have provided in connection with the Services. You further understand and agree that it is your responsibility to monitor and respond to these messages, reports, and emails.
3.Eligibility. The Services are not intended orde signed for individuals under the age of 18 or under the age of majority in their jurisdiction of residence. By using the Services, you confirm that you are age 18 or over the applicable age of majority in your jurisdiction of residence.
The Services are intended for individuals located and residing in the United States. However, the Services may not be available in certain U.S. states or territories. You will be notified if the Services are not available in the state or province/territory in which you are located. You agree that any and all data you provide or make available in connection with the Services shall relate only to users located in the United States. By using the Services, you confirm that you are located in the United States when you receive the Services. You shall not access the Services outside of the United States and DNAvisit disclaims any responsibility for any attempt by you to do so.
You agree that any data submitted or provided by you or on your behalf in connection with the Services is truthful, accurate, and appropriate. You agree that the Services that you request are for your own personal use and that you will not order a Test for another person.
You may be ineligible to receive DNAvisit Services, or certain Tests may not be recommended for you, based on the information that you provided or otherwise, and you will be notified if this is the case.
4.Payment. Laboratory will collect your payment for the Services on behalf of DNAvisit as its collection agent.
The Services are paid for by you and are not intended to be reimbursed by any health insurance plan. DNAvisit does not submit or process insurance paperwork or claims related to this service.
For U.S. Residents Only: By continuing with the Services, you understand and agree that you are responsible for paying all fees associated with the Services being offered through DNAvisit, including any fees charged by medical providers and affiliated professional entities for professional services. While we are aware that some health insurance plans may offer coverage for certain services (including testing services), the medical providers and affiliated professional entities providing Services have not contracted with any health insurance plans to make these services available. You may request that DNAvisit provide you with a detailed accounting of the Services provided to you. This information may enable you to obtain reimbursement for your out-of-pocket expenses from your health insurer. However, the terms and conditions of coverage for services and testing vary by plan, and the Services offered by DNAvisit may not be eligible for coverage or expense reimbursement.
5.Test Request Review. DNAvisit affiliated independent physicians review Test requests and determine whether testing is appropriate for you.
6.Genetic Counseling. A DNAvisit genetic counselor may contact you prior to the Test(s) to obtain additional information to determine if the Test(s) is appropriate for you. DNAvisit may also offer post-test genetic counseling, as applicable.
7.Privacy. Please review the applicable Notice of Privacy Practice, which describe DNAvisit’s practices regarding the information that DNAvisit may collect from users of the Services. By using the Services, you hereby consent to all actions we may take with respect to your information consistent with these Terms and the applicable Notice of Privacy Practice/Canadian Privacy Notice, and the consent that you have/will sign upon ordering of the Tests.
8.Limitation of Liability. In no event will DNAvisit or its affiliates and their respective officers, directors, employees, agents, partners, licensors, physicians, genetic counselors, healthcare providers or service providers be liable to you or to any party for any indirect or consequential damages relating to. use of (or inability to use) any services.
9.Disclaimers. DNAvisit does not make any representations, warranties or endorsements regarding any services provided by third parties including, without limitation, services provided by laboratory, and/or other providers of laboratory services. DNAvisit is not responsible for any errors or omission in the information you provide or that is provided to DNAvisit on your behalf.
10.Indemnification. You agree that you will be responsible for your use of the Service, and you agree to defend, indemnify and hold harmless DNAvisit and its officers, directors, employees, consultants, affiliates, subsidiaries and agents (collectively, the 'DNAvisit Entities') from and against any and all claims, liabilities, damages, losses and expenses, including reasonable attorneys' fees and costs, arising out of or in any way connected with (i) your access to, use of, or alleged use of the Service, or (ii) your violation of these Terms or any representation, warranty or agreements referenced herein, or any applicable law or regulation. We reserve the right, at our own expense, to assume the exclusive defense and control of any matter otherwise subject to indemnification by you (and without limiting your indemnification obligations with respect to such matter), and in such case, you agree to cooperate with our defense of such claim.
11. Ownership; Intellectual Property and Proprietary Rights. All content, text, graphics, logos, icons and images provided by DNAvisit through or in connection with the Services, and all intellectual property rights therein, and any suggestions, ideas or other feedback provided by you, are the sole and exclusive property of DNAvisit or our service or content providers and are protected by United States and foreign intellectual property laws. The Services also contain proprietary and confidential information that is protected under U.S. and foreign intellectual property laws, including copyright, trademarks, service marks, patents or other proprietary rights and laws.
Except as expressly authorized by DNAvisit, you may not use, sell, modify, reproduce, distribute, create derivative works of or otherwise exploit any information or content made available to you on or through the Services, in whole or in part. DNAvisit grants you a limited, non-exclusive right to access and use the Services solely for personal, non-commercial purposes on the condition that you comply with these Terms. Any use of the Services other than as specifically authorized herein is strictly prohibited.
Certain names, logos, brands and other materials displayed in connection with the Services may constitute trademarks, trade names, services marks or logos ('Trademarks') of DNAvisit or its affiliates. You are not authorized to use any such Trademarks without the express written permission of DNAvisit or its affiliates. Ownership of all such Trademarks and the goodwill associated therewith remains with us or our affiliates.
DNAvisit and our service providers, and our successors and assigns, may use, copy, reproduce, modify, analyze, perform, display, distribute and otherwise disclose to third parties any data for purposes of providing Services to you; conducting research or analyses of such data; and designing, developing, implementing, modifying and/or improving new, current or future features, products and services of DNAvisit using such data.
All rights not expressly granted in these Terms are reserved.
12. Term; Termination. The Terms, as may be amended from time to time, will remain in full force and effect as long as you continue to access or use the Services, or until terminated in accordance with the provisions of these Terms. We, in our sole discretion, with or without notice to you, at any time and for any reason, may terminate, suspend or modify: (i) any of the rights granted by these Terms; (ii) the permission granted to you to access and/or use the Services; and (iii) the Services. You may terminate the Terms at any time by discontinuing use of the Services. Your permission to use the Services automatically terminates if you violate these Terms. DNAvisit shall not be liable if, for any reason, all or any part of the Services is unavailable. Upon termination of these Terms, any provision that by its nature or express terms should survive will survive such termination.
13.Equitable Relief. You acknowledge and agree that breach of these Terms will result in irreparable harm that would be difficult to measure; and, therefore, that upon any such breach or threat of such breach, DNAvisit shall be entitled to seek injunctive and other appropriate equitable relief from any court of competent jurisdiction (without the necessity of proving actual damages or of posting a bond), in addition to whatever remedies it may have at law, under these Terms, or otherwise.
14.General. These Terms, the applicable Notice of Privacy Practice/Canadian Privacy Notice, consents and any other agreements incorporated by reference herein constitute the entire agreement between you and DNAvisit with respect to access to and use of the Services. These Terms and your use of the Services are governed by the laws of the State of Delaware, without respect to its conflict of law principles. In the event a dispute arises between the parties under these Terms or that in any way relates to your use of the Services, the parties hereby agree to binding arbitration, which will be conducted in Houston, Texas, in accordance with the Commercial Arbitration Rules of the American Arbitration Association. If any provision of these Terms is found to be invalid or unenforceable by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms, which shall remain in full force and effect. No waiver of any of these Terms shall be deemed a further or continuing waiver of such term or condition, or of any other term or condition. You may not assign or transfer your rights or obligations under these Terms without our prior written consent, and any assignment or transfer in violation of this provision shall be null and void. There are no third-party beneficiaries to these Terms. DNAvisit may freely assign or transfer these Terms without restriction. Subject to the foregoing, these Terms will bind and insure to the benefit of the parties, their successors and permitted assigns.
15.Contact us. Should you have questions about the Services, including about your Test or Results, you may email us at email@example.com.
10210 Campus Point Dr Suite 150 San Diego, CA 92121
Notice of Privacy Practices Regarding Health Information
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
How we May Use and Disclose your Health Information. We may use your health information and disclose it to appropriate persons, authorities and agencies, as allowed by federal and state law. Please be aware that state and federal law may have more requirements on how we use and disclose your health information. If there are specific, more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. We may also be required by law to obtain your written permission to use and disclose your information related to treatment for a mental illness, developmental disability, or alcohol or drug abuse. We may do this without your written permission for the following limited purposes:
3.Required by Law.
5.Reporting Victims of Abuse or Neglect.
6.Health Care Oversight.
7.Legal Proceedings & Law Enforcement.
9.Serious Threats to Health or Safety.
Contact us with any questions or concerns regarding the above by emailing firstname.lastname@example.org.
Attn: Privacy Officer
10210 Campus Point Dr. Suite 150 San Diego, CA 92121