Consent and Terms of Service

 
 

If you think you may have a medical emergency, call your doctor, go to the emergency room, or call 911 immediately. Clover Genetics does not manage emergency care.

Clover Genetics, LLC provides genetic counseling and consulting services consistent with, and not beyond, the genetic counselor’s scope of practice defined by the National Society of Genetic Counselors (NSGC) and the American Board of Genetic Counseling (ABGC).

  • Clover Genetics does not provide medical advice. No information on the Clover Genetics website, received verbally, written, or digitally, should be used or intended for medical diagnosis or treatment.

  • The information provided through genetic counseling services should not be taken as a reason to disregard any other medical diagnosis or medical advice from a physician.

  • Seek the advice of your physician or a qualified healthcare professional with any questions you may have regarding any medical condition.

  • Clover Genetics does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned by Clover Genetics or in consultation. Reliance on any information provided by Clover Genetics or its employees or contractors is solely at your own risk.

  • If you receive services via telehealth, you attest that you are physically located in a state or country where the scheduled genetic counselor is permitted to provide services. Clover Genetics will verify the counselor’s licensure in the state where you are physically located at the time of the appointment and may reschedule or refer you if licensure or legal limitations prevent service. It is your responsibility to inform us if your physical location changes before or during a telehealth appointment. (See the Telegenetics guidance from NSGC for more on telehealth practices.)

CONFIDENTIALITY:

All ethical standards prescribed by state and federal law are followed by Clover Genetics. Retained records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you. Discussions between the genetic counselor and you, the client, are confidential. No information will be released without your written consent unless mandated by law. Possible exceptions to confidentiality include, but are not limited to: abuse of children, elders, the disabled, patients in mental health facilities, or any other demographic; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the Genetic Counselor has a duty to disclose, or where, in the Genetic Counselor’s judgment, it is necessary to warn or disclose; fee disputes between Clover Genetics and the client; a negligence suit brought by the client against Clover Genetics; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the staff to discuss this matter further.

By signing our Consent Form, you are giving consent Clover Genetics to share confidential information with all persons mandated by law and with the agency that referred you and any insurance carrier you wish to involve for payment of genetic counseling services. By signing this Consent Form you authorize Clover Genetics to disclose PHI as required for treatment, payment, or healthcare operations, and to agencies or insurers as needed for billing or mandated reporting. You understand that Clover Genetics cannot prevent disclosures required by law (for example, mandatory reports of suspected abuse, duty to warn, or subpoenas). This form is not a waiver of any legal rights and does not limit disclosures that may be required by law or court order.

How does Clover Genetics Use Protected Health Information (PHI):

How we use and protect your PHI: To provide services we collect and store PHI (e.g., name, DOB, contact info, clinical records, payment info). Records are stored electronically under Business Associate Agreements (BAAs) with our vendors (currently: Google Workspace and Simple Practice). While we use administrative, technical, and physical safeguards to protect PHI, no electronic system is 100% secure. If you prefer an encrypted method of communication, request it via [info@clovergenetics.com]. Clover Genetics will follow federal breach-notification rules and will notify affected individuals as required by HHS in the event of a reportable breach. You have rights to access and request amendment of your records; contact our Privacy Officer at [info@clovergenetics.com]. We retain protected health information consistent with applicable law.

By using this website and receiving services, you agree not to misrepresent yourself or your health history, family health history, health information, state of residence, or current location while receiving services. You agree not to share confidential information about any individual other than yourself unless you are legally authorized to do so.

REPORTING OF UPDATED HEALTH INFORMATION, STATUS CHANGES, OR DIAGNOSES:

Additional diagnoses for yourself or family member can impact risk assessment and associated recommendations. Recommendations or availability surrounding genetic tests may change over time along with the recommendations for medical management, such as screening and treatment options. The responsibility for follow-up rests solely with you to reach out to a qualified healthcare professional to report any changes to health history and discuss updates and available options for genetic testing and associated recommendations.

  • Genetic counseling requires current and accurate health history and medical records in order to ensure risk assessment and appropriate recommendations. If after an appointment you obtain updated information, you are encouraged to share the new information with Clover Genetics, knowing that it may indicate a follow-up consultation to provide an updated risk assessment.

  • If the new information is not related to the original indication for genetic counseling, a new consultation fee will be incurred.

  • If a client seeks genetic counseling services elsewhere for any indication, we encourage sharing of information received during your consultation with Clover Genetics. Clover Genetics will assist with sharing documents with your approved providers according to HIPAA guidelines.

DISCUSSION AND COLLABORATION WITH OTHER HEALTHCARE PROVIDERS:

Clover Genetics, is a standalone entity not associated with any other healthcare institution. The decision and responsibility of sharing or not sharing information from the consult is solely that of the client. We are not responsible for making first contact with any of your healthcare providers. If your healthcare provider contacts Clover Genetics with your verbal or written permission, we will speak to the provider to help with coordination of care. This does not incur any additional fee, however, there is no obligation for Clover Genetics to assist.

INDIVIDUALS UNDER 18 OR THOSE CONSIDERED MINORS IN THEIR JURISDICTION:

Minors (clients under 18): For clients who are minors, a parent or legal guardian must provide consent unless the minor is emancipated or permitted to consent under state law. Parents/legal guardians may have access to the minor’s records as required by law. We will attempt to involve older minors in the counseling process consistent with professional standards.

STORAGE OF RECORDS:

Clover Genetics is a paperless company meaning we do not keep any physical hard copy records of PHI (Protected Health Information). Access to any record is protected by passwords. Any records received or produced in the process of a consultation are stored in a cloud-based method with a third party. These are done so in practice of a Business Associate Agreement (BAA). BAAs legally obligates a party to ensure measures to protect PHI from unauthorized use or disclosure. Although numerous measures are taken to protect an information entered, complete security can’t be guaranteed, thus by using Clover Genetics website and services, you accept the associated risks to your privacy and information. Clover Genetics holds a BAA with: Google Workspace and DoxyMe.

ELECTRONIC COMMUNICATIONS:

Emails originating from @clovergenetics.com is a functionality of Google Workspace and thus associated with the Clover Genetics BAA with Google. However Google Workspace in isolation can not guarantee encryption and protection of email communication. Clover Genetics holds a BAA with Identillect Technologies providing encryption services. Clover Genetics cannot guarantee or be held responsible for the security of information sent via an unencrypted email. If you choose to communicate via an unencrypted email instead of through an encrypted method, you accept the increased risk to your information. Any information you print or store locally is solely your responsibility.

CLIENT/PROFESSIONAL RELATIONSHIP:

You and your healthcare provider have a professional relationship existing exclusively for genetic counseling. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic and medical education aspects.

RISKS AND BENEFITS:

Genetic counseling can be beneficial, but as with any type of health care service treatment, it is not without risks. During the genetic counseling process, you will have discussions about health history, family history, and personal issues, all of which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. Genetic testing can also include risks such as variants of uncertain significance which may not provide sufficient information in order to direct decision making, changes to insurance (particularly Life and Long Term Disability) based on identification of health risks in genetic testing. Possible benefits include increased knowledge regarding genetics, including your specific personal and family health history, information that may be used to inform management (with consultation of a physician), reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits.

Federal law (Genetic Information Non-Discrimination Act - GINA) generally prohibits genetic discrimination in health insurance and employment, but does not cover life insurance, disability insurance, or long-term care insurance. State laws vary and may provide additional protections. Before genetic testing you should consider discussing insurance risks with a qualified professional. For more information see HHS/NIH guidance on GINA.

TELE-COUNSELING:

Telegenetics (tele-health) is the use of electronic transmissions to communicate what would traditionally be conferred through a face to face genetic counseling visit. In this case, we offer both video and audio forms of communication via the phone or internet. This means the practice of genetic counseling and education using interactive audio, video, or data communications. The risks involved with telegenetics include the potential release of private information due to interception during transmission. There is the risk of being overheard by anyone near you if you do not place yourself in a private area. You are responsible for information security of your computer/device. If you decide to keep copies of any record or communication, it’s up to you to keep that information secure. Clover Genetics cannot guarantee the security of our emails on your server.

PROCEDURES REGARDING LEGAL PROCEEDINGS:

For legal requests (records, subpoenas), Clover Genetics will provide documents in accordance with legal requirements. We will provide an estimate of fees for time spent and copy costs. Attorneys requesting records must provide written authorization and will be billed. If court attendance is required, standard hourly rates will apply.

Some federal and state healthcare programs, including Medicare and Medicaid, place restrictions on when beneficiaries may privately pay (“self-pay”) for services that may otherwise be covered under those programs. Because these rules vary by program and by state, Clover Genetics may not be able to offer self-pay genetic counseling services to certain Medicare or Medicaid beneficiaries. Eligibility is determined on a case-by-case basis based on applicable laws and regulations in effect at the time of service.

You agree to notify Clover Genetics if you are enrolled in Medicare or Medicaid so that we may determine whether services can be provided in compliance with applicable regulations. If services cannot be provided, we will inform you prior to the appointment whenever possible.

FEES FOR SERVICE:

At the time of scheduling an appointment you accept that you will pay the fee associated for the service indicated on the website listed under the payment portal. When booking your appointment, you will be charged $150, half the fee of a full appointment, that goes toward your one hour appointment fee. Payment of the remaining balance will be charged to your on-file card upon completing the appointment. This totals $300 per one-hour appointment.

  • Requests to reschedule can be accommodated at no additional charge only if request is made greater than 48 hours in advance of the time of the original appointment.

  • A deposit to hold the appointment will be made prior to your visit. This will total $150 and will cover the first half hour of your appointment.

  • Cancellations made less than 48 hours in advance will not be refunded the $150 deposit fee. Sliding Scale cancellation fees will reduce based on approved appointment total.

  • Incomplete or inaccurate information provided may result in the need for another consult and additional fees.

  • If I ‘No-Show / No-Call’ for my appointment, defined as not being present for your appointment more than 15 minutes after the scheduled time, you will be billed a no-show fee equal to a 30 minute session, $150, that will be required to be paid prior to rescheduling.

  • I understand that each initial genetic counseling session may last beyond the 30 minute time up to 60 minutes maximum.

    • If the initial time is exceeded, an additional appointment may need to be scheduled at the same follow-up rate billed in 30 minute increments.

  • I understand that if I am late to the appointment, I will still have to end the session at the allotted time.

  • It is policy to charge for other professional services you may require such as: telephone conversations which last longer than 15 minutes or attending meetings or consultations with other professionals which you have authorized.

  • I understand, that charges billed by Clover Genetics are for professional services only. Any charges for genetic testing will be directly between the genetic testing lab and the patient/guarantor and are their sole responsibility.

PAYMENT CONSENT:

I authorize Clover Genetics to charge my credit/debit/health account card for professional services and auto-pay after the session is complete unless requested otherwise in writing by the patient or family.  I recognize that Clover Genetics has the right to charge my card as a late cancel or no show as described above if I do not show up for the appointment.  I will be billed for the full 30 minute session charge based upon the rates published on Clover Genetics at time of scheduling. I verify that my credit card/payment information provided is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance may be forwarded to collections as allowed by law if another alternative payment is not made within thirty days.

INSURANCE:

Out-of-Network: At this time, Clover Genetics does not accept most insurances. A copy of your receipt may be used to submit to your insurer for reimbursement, but this is your sole responsibility. Clover Genetics will not advise on the likelihood of coverage or process insurance submission at this time. I understand if I involve my insurance for payment that I am responsible for knowing my co-payment amount and deductible amount, but that I will have to pay the Out-of-Pocket fees up-front before appropriately requesting reimbursement from my insurance. I understand that these charges are an Out-of-Pocket expense and that my insurance carrier may not reimburse these charges.

Authorization to Pay Insurance Benefits: By signing below, if Clover Genetics and I choose to involve an insurance provider, I hereby authorize payment directly to Clover Genetics. I understand that I am financially responsible for all fees incurred and for fees not covered by this authorization. I authorize the release of my medical information to my third party payer in order to obtain payment for insurance reimbursement purposes if I choose to bill insurance. I hereby authorize Clover Genetic to release any medical information required for assessment. I understand that payment is expected prior to rendering of services unless other arrangements have been made. I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient, authorized to furnish the information requested. I understand that even if I have some type of insurance coverage, I am responsible for full payment of services.

CONSENT TO CONSULTATION:

By signing this form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this Client Consent form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive genetic counseling services and I understand that I may stop services at any time.

NOTE: By signing this form I am also acknowledging that I have read and understand the Notice of Privacy Practices, Privacy Statement, and Terms of Service compliance paperwork all of which are available on clovergenetics.com.