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MLH MSH Consent Form Mobile App

The MLH MSH Consent Form mobile app includes an informed consent and requisition for laboratory testing. Informed consent MUST be signed by patient, parent/legal guardian or legal next of kin. The app requests the following tests: genetic testing. You can customize the amount of time the GoCanvas Smart Client on the mobile device can go without successfully authenticating against the GoCanvas servers.

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Included Features

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Included Fields

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Type of specimen:
REQUEST FOR MOLECULAR TESTING FOR (Specify all tests that are being ordered)
This form must be completely filled out and signed by patient, parent/legal guardian or legal nex...
REQUESTING PHYSICIAN, M.
Telephone No.
ID Code:
CONDITION (Purpose of Testing)
In accordance with State Law, the following has been discussed with the patient/legal guardian a...
Name of Person Obtaining Consent
Signature:
Title
Date:
Informed Consent/Advance Beneficiary Notice: Please read carefully and discuss with your ordering...
The condition stated above has been described to patient/legal guardian in detail.
2. The tests ordered above are for molecular genetic (DNA-based) tests to detect a mutation, or c...
The patient/legal guardian may wish to obtain genetic counseling prior to signing this consent f...
When DNA testing detects the most common disease-causing changes in a gene, the test result is h...
The results of the testing may 1) indicate a predisposition to have the above specified conditio...
A positive test result will help determine that a patient has the specified condition, or that t...
When DNA testing does not show a known genetic change, the chance that a person is a carrier or ...
In some families DNA testing may discover non-paternity (someone who is not the real father), or...
The results of the above tests become part of the patient's medical record.
Current State law prohibits discrimination by insurance carriers based on results of genetic tests.
10. (Initial One)
I authorize
I do NOT authorize the staff of the medical genetics staff of Hospital to make the results these ...
No tests other than the tests specifically authorized above will be performed on this sample, un...
Advanced Beneficiary Notice: Medicare/Insurance carriers may not pay for the testing, in which c...
...and More!

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More Information

Creator: Team GoCanvas
Language: English
Country: United States of America
Type: Authorizations
Tags:
Pathologist, Pathology
Categories:
Health Care & Social Services, General Health Care & Social Services, Pathologist