Tempus Patient Consent for Testing
Your healthcare provider has ordered genetic test and analysis (hereinafter the “Test”) to obtain additional information that may inform medical management of your condition. This document describes the potential risks, benefits, and limitations of the Test. If you have any questions or need additional information, please consult your healthcare provider before signing. You are not required to have this Test. If you decide to authorize the Test, please sign and date where indicated at the end of this document.
Purpose & Process
Tempus (or its licensed, third-party contractor) will perform genomic profiling and analysis of certain regions of your DNA that may be associated with your condition, and Tempus will report Test results to your healthcare provider. Depending on your DNA, the Test may indicate whether you have one or more inherited genetic variants that may be associated with the metabolism of certain therapies. Tempus will work with your healthcare provider to obtain a biological sample and information from your electronic health record and/or other information related to your clinical care. Genetic material, including DNA and RNA, will be obtained from samples, stored, and analyzed. In order to improve the quality of our testing, Tempus may retain your tissue, cells, and/or DNA or RNA extracted from your cells for an indefinite period of time following the testing ordered by your healthcare provider and use leftover materials for internal purposes, including quality assurance and test validation. Tempus may also remove directly identifying information from these materials and use them for research purposes, including future research related to diagnosis, testing, and therapies.
Risks, Benefits, & Limitations
Tempus’ Test report does not provide any medical diagnosis and does not make any specific treatment recommendations; instead, it provides information for your healthcare provider to review. There is no guarantee that performance of the test will yield clinically relevant information, inform your healthcare provider’s clinical decision-making or otherwise lead to any particular or beneficial outcome for you. Knowledge about the effects and meaning of genetic changes is constantly changing. This Test does not examine every possible variant that may exist, and the technology also may not identify all variants related to your condition, because there is a possibility of testing errors by Tempus (or its contractors) and because some biological factors may limit the accuracy of results. Tempus is under no ongoing obligation to update, revisit or later re-evaluate the results of the Test after those results have been made available to your healthcare provider through the test report described above. To learn more about genetic testing, you may want to speak with a genetic counselor before and/or after testing. If you want to talk to a genetic counselor, you can ask your healthcare provider to refer you to one. You are required to sign this consent in order to receive testing from Tempus, and your signature below indicates that you have read and understood the information and are agreeing to have the Test.
Assignment of Insurance Benefits; Authorization; Appointment as Legal Representative
I hereby assign all applicable health insurance benefits and/or insurance reimbursement I have under my health plan(s) to Tempus Labs, Inc. (“Tempus”) for services performed by Tempus. I also appoint Tempus as my authorized representative and convey to Tempus, to the full extent permissible under the law, the power to: (1) file medical claims with the health plan; (2) file appeals and grievances with the health plan and/or any agency or governmental body with applicable authority; (3) obtain and release, medical records and insurance information as necessary to process a claim, appeal or grievance; and (4) collect payment of any and all medical benefits and insurance proceeds (including Medicare and Medicaid). The above appointment and conveyance includes all my rights in connection with any claim, right, or cause of action including litigation against my health plan that I may have, including, the right to claim on my behalf, all such benefits, claims, or reimbursement, and to seek any other applicable remedy, including fines.
Specimen Release
I authorize the release of my clinical specimens and other materials, including extracted DNA and RNA, that are requested by Tempus (“Materials”), and I hereby direct the healthcare provider office/clinical laboratory receiving this request to release and provide all such Materials to Tempus. I understand that the Materials may be irreplaceable and could be lost or damaged in handling, transit or when used. I agree to release Tempus and any clinical laboratory releasing such Materials from any claims I may have for any such loss or damage to the Materials.