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 receiving counseling services via telegenetic methods, signing this consent recognizes your explicit confirmation that you will confirm ahead of your appointment you are located in a state or country eligible for being seen by the genetic counselor with whom you’re scheduling your appointment:

    • Verify your location does not have a licensing requirement for genetic counselors as of the date of your appointment

    • Confirm the genetic counselor you are scheduled to see holds a license in the state you will be residing in during your scheduled appointment

    • Know that if you are located in a different state or country at the time of your appointment than when you registered, you must reverify your eligibility prior to your appointment date

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. You also release and hold harmless the undersigned, Andrew McCarty, Rachel Baer, or any Clover Genetics Contractor or Staff from any departure from your right of confidentiality that may result.

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

Use of Clover Genetics requires sharing of PHI, which may include, but is not limited to: name, date of birth, telephone number, email, bank account, and debit/credit card information. By receiving services from Clover Genetics you accept the security of your information can never be completely guaranteed despite the measures taken to protect it.

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:

If you are considered a minor based on the laws governing your residence, your parent/guardian may potentially be legally entitled to certain information regarding the consultation with Clover Genetics. Excluding emancipated minors, Clover Genetics cannot see patients under the age of 18 without explicit documented consent from their parent or legal guardian; seeing minors without accompanying parents/guardians is at the discretion of Clover Genetics.

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.

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 any legal proceedings initiated or requested by the patient or their representatives, any attorneys requiring confidential information on clients will be billed for the information released, the time required to compile the information and any materials or postage necessary. The attorneys will also be billed for all court costs incurred. This will include preparation time, actual court appearance, and travel time. The fee involved for these services will be $100.00 per hour. In the event that the attorneys fail to pay for these services, the balance due will be the responsibility of the person or persons signing this Agreement. Be advised that insurance DOES NOT cover this and would be considered a full out of pocket expense, required to be paid in full upfront.

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. Payment of fees are requested in full, unless a sliding payment schedule has been arranged prior.

  • 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.

  • Cancellations made less than 48 hours in advance will be charged $50.

  • Cancellations made less than 24 hours will be charged the full fee of the appointment.

  • 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 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.

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 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.