Consent For Release Of Information Form
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7Protocol: Out-of-Province Genetic Testing Coordination
Division of Laboratory Genetics, Molecular Genetics Laboratory
The following protocol is the responsibility of the Ordering Physician; MGL provides ‘shipping
and handling’ services only.
STEP ONE: Request Funding.
FUNDING MUST BE SECURED PRIOR TO SAMPLE COLLECTION.
1.
Choose a Testing Laboratory. Resources:
and
2.
Obtain from the Testing Laboratory:
a.
Requisition;
b.
Consent form, if applicable;
c.
Billing form, if applicable;
d.
Cost of the test;
e.
Turnaround time;
f.
Sample Requirements: confirm that 4 mL EDTA peripheral blood is sufficient.
i. For other sample sources (frozen or paraffin tissue, amniocentesis, CVS): Discuss with MGL prior to
arranging testing.
3.
Submit the MSP application form:
If MSP Funding is Approved:
STEP TWO: Complete the Required Paperwork.
1.
Testing Laboratory Requisition and any associated paperwork such as billing form or consent form.
Ensure that you provide complete information, including Ordering Physician name and contact information.
Request “institutional billing” and state:
Bill at your institutional rate to:
Ms. Kelly Braithwaite
Authorization Coordinator
HIBC Out of Country Claims
P.O. Box 9480 Stn Prov Govt
Victoria, BC V8W 9E7 CANADA
Include the patient name, PHN, referring physician name, and report with the invoice.
2.
Request for Shipment for Out-of-Province Genetic Testing Form
3.
Consent to Release Information Form
This form is only required if the Testing Laboratory is located outside of Canada, and MUST be completed in full
at the time of patient signature.
STEP THREE: Fax completed paperwork to MGL at 604-875-2707, in the following order:
a. Request for Shipment for Out-of-Province Genetic Testing Form
b. Testing laboratory requisition, billing form, and consent form, if applicable
c. MSP funding approval letter
d. Consent to Release Information form, if applicable
STEP FOUR: Arrange Sample Collection.
1.
Complete the MGL General Requisition:
a.
Sample type: EDTA blood
i. If > 4 mL EDTA blood required for testing, specify volume.
Test requested: Other “MSP funded: [Test Name]”
b.
Send patient for blood collection. Patient’s can have their sample collected at any BC collection facility.
2.
Upon sample receipt, MGL will:
ship the entire blood sample and paperwork to the referral laboratory;
send a letter to the referring physician, confirming the shipment, including date sent, to allow for tracking.
STEP FIVE: Track results and report directly with the Testing Laboratory.
Document # CWMG_REQ_0210P Version 3.4 Revised: April 2015
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