GENESIGHT TESTING CONSENT & INFORMATION FORM

This form authorizes AccuGen Diagnostics LLC to collect your sample and submit it for GeneSight pharmacogenomic testing. GeneSight helps your provider understand how your genes may affect your response to certain mental health medications. Your information is kept confidential and used only for testing, reporting, and clinical coordination.

ICD‑10 Diagnosis Codes (Required for insurance billing)

Please list all applicable mental health–related ICD‑10 codes provided by your clinician.

Examples include (but are not limited to):

• F32.0–F33.9 – Major Depressive Disorder

• F41.1 – Generalized Anxiety Disorder

• F41.0 – Panic Disorder

• F43.10 – PTSD

• F90.0 – ADHD

• F31.9 – Bipolar Disorder

Current Medications include Dosage

Consent for GeneSight Testing

I authorize AccuGen Diagnostics LLC to collect my sample and submit it to GeneSight for pharmacogenomic testing. I understand that:

• GeneSight testing analyzes how my genes may affect my response to certain medications.

• Results will be shared with my ordering provider to support treatment decisions.

• This test does not diagnose or treat any condition.

• My information will be kept confidential and used only for testing and reporting.

• I may request a copy of my results at any time.

Authorized Representative

Aliya Simpson CPT