By ticking this box, I certify that I am a licensed medical professional or his/her representative or a genetic counselor authorized to order
genetic testing. My signature further acknowledges the patient has been supplied information regarding genetic testing and has been
informed about the purpose, limitations and possible risks. The patient has been given the opportunity to ask questions about this consent
and seek outside genetic counseling. The patient has given consent for genetic testing to be performed and the signed consent form is on
file. I confirm that this testing is medically necessary for the specified patient, and that these results will be used in the medical management and
treatment decisions for this patient.
I confirm that the patient has been informed and hereby authorizes (i) KIBs to release information concerning their testing to their
insurer in order to obtain reimbursement for the testing services; (ii) KIBs to be paid directly by the insurer for services rendered;
and/or if applicable (iii) KIBs or its affiliates to be the patient’s designated representative for the purpose of appealing any denial
of insurance benefits. I confirm the patient fully understands they are legally responsible for sending KIBs any and all of the
money that they receive directly from their insurance company in payment for this testing.