Assess your Hereditary Cancer Risk

Know Your Family History

This Knowledge Could Be Life-Saving.

Please fill in the name and type of cancer of each family member affected.
Person Affected
Mother’s Side
Father’s Side

If you answered “yes” to any of these questions, you may consider further evaluation of your risk of developing a hereditary cancer with a genetic counselor.

“You will be contacted by a patient advocate with Hopes Source (www.hopessource.org) to discuss the next steps prior to scheduling the Genetic Counselor appointment. Your insurance information will not be used until you verbally confirm that you would like to move forward with the appointment.”

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment upon execution of this consent.
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CANCER GENETIC CONSULT REFERRAL FORM

PHYSICIAN INFORMATION:

PATIENT INFORMATION:

INSURANCE:

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CLIA # 11D2084528 11535 Park Woods Circle, Suite E; Alpharetta, GA 30005 1-855-647-4363 www.mygenomics.com MGV104/09-16

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