I verify that all specimens submitted by me, or an authorized individual on my behalf, to Genotox Laboratories LTD are my own. I have not adulterated or tampered with them in any way. I am submitting this specimen for analysis by Genotox Laboratories LTD. I authorize Genotox Laboratories LTD (Genotox) to test all specimens received at the lab that belong to me. I authorize my test results to be released to my supervising organization. Genotox Laboratories LTD will handle my protected health information (PHI) in compliance with HIPAA requirements and any state laws that are applicable. I understand that Genotox laboratories LTD reserves the right to use my de-identified information (the removal of my protected health information from my results that identifies it as mine) for research, validation, and accreditation purposes.
I acknowledge that Genotox Labs will permanently destroy my genetic data only upon written request from me and/or my supervising organization requiring testing. I acknowledge that Genotox Labs may inform my supervising organization of my request to destroy genetic data.