BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
WHOLE EXOME SEQUENCING (WES) REQUISITION
PATIENT INFORMATION (COMPLETE ONE FORM FOR EACH PERSON TESTED)
Patient Last Name: FRANCE Patient First Name: N/A / N/A / N/A MI: NONE Date of Birth (MM / DD / YYYY): 888-0888-9999
Address: 404 Exp... Ave City: BRAMA State: STATE Zip: NONE Phone: _____
Accession #: _____ Hospital / Medical Record #: _____
Genetic Sex: Female Male Unknown
Gender identity (if different from above): _____
Note: All reports will be sent via fax except for international recipients.
ORDERING PHYSICIAN
Ordering Physician: Michael Brittany Institution Code: H+H
Institution Name: Hospital Hospital
Email (Required for International Clients): michael.britt@... ...
Phone: 252-288-1831 Fax: None as none
ADDITIONAL REPORTS
Name: Fathers Name Failed to save Name: Patrisha
Email: fathermenname@...com Email: Patrisha.egym~
Phone: / / .. Phone: _____ Fax: ↓
Note: Reports will be sent by FAX except for international recipients
PAYMENT (FILL OUT ONE OF THE OPTIONS BELOW)
SELF PAYMENT
Pay With Sample Bill To Patient Great care into mum's cashes
INSTITUTIONAL BILLING
Institution Name: _____ Institution Code: _____ Institution Contact Name: _____ Institution Phone: _____ Institution Contact Email: _____
X INSURANCE
Do not perform test until patient is aware of out-of-pocket costs (excludes prenatal testing)
REQUIRED ITEMS 1. Copy of the Front/Back of Insurance Card(s) 2. ICD10 Diagnosis Code(s) 3. Name of Ordering Physician 4. Insured Signature of Authorization ICD10 Diagnosis Code(s) (Required)
Commercial Medicaid Medicare*
*A completed Advance Beneficiary Notice (ABN) is required for Medicare patients that do not meet Medicare criteria.
Has the patient been a hospital inpatient in the last 14 days?
No, the patient was not an inpatient Yes, the patient was an inpatient (hospital stay longer than 24 hours)
| Primary Insurance Co. Name | Primary Insurance Co. Phone | Secondary Insurance Co. Name | Secondary Insurance Co. Phone |
| Primary Member Policy # | Primary Member Group # | Secondary Member Policy # | Secondary Member Group # |
| Name of Insured | Inured Date of Birth (MM / DD / YYYY) | Name of Insured | Inured Date of Birth (MM / DD / YYYY) |
| Patient's Relationship to Insured | Phone of Insured | Patient's Relationship to Insured | Phone of Insured |
| Address of Insured | Address of Insured | ||
| City | State Zip | City | State Zip |
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. If self-pay is selected, I agree to pay for the cost of testing ordered and billed by Baylor Genetics as outlined in the Good Faith Estimate I received. I understand that I am responsible for sending Baylor Genetics any and all payments that I receive directly from my insurance company in payment for this test. Please note, Medicare may not cover certain screening tests.
Patient / Guardian Printed Name: _____ Patient / Guardian Signature: _____ Date (MM / DD / YYYY) _____
1 // 9
BAYLOGENETICS.COM
03.24.24
BAYLOR GENETICS 2450 HOLCOMBE BLVD. SUITE 2210 HOUSTON, TX 77021-2024
PHONE 1.800.411.4363 FAX 1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
LP LAnn Patient Last Name
Fare Patient First Name
IMI
Sly / Behm / 1961 Date of Birth (MM / DD / YYYY)
Poule Genetic Sex
STATEMENT OF MEDICAL NECESSITY AND CONSENT TO TERMS & CONDITIONS FOR TEST ORDER (REQUIRED)
This requisition hereby incorporates the Terms and Conditions of the Laboratory Services found at https://www.baylorgenetics.com/lab-terms-conditions/ or, in the case of international entities...
Physician's Printed Name Physician's Signature
Date (MM / DD / YYYY) 01 / 01 / 2022 04 / 26 / 2006
INSTRUCTIONS FOR ORDERING
Familial samples are required for non-Proband WES. Please contact the laboratory if placing a test order where the comparator(s) are different than the required family members listed.
For select cases as determined by Baylor Genetics, WES may be supplemented by RNA-Seq to aid with variant classification as a standard part of this test offering...
TRIO WES TEST OPTIONS
1600 Trio Whole Exome Sequencing 1722 Rapid Trio Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS (Both Biological Parents Are Required) 1560 Comparator WES 1602 WES - Additional Affected Sibling
DUO WES TEST OPTIONS
1603 Duo Whole Exome Sequencing 1723 Rapid Duo Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS (One Biological Parent Is Required) 1550 Comparator WES 1602 WES - Additional Affected Sibling
PROBAND WES TEST OPTIONS
1500 Proband Whole Exome Sequencing 1729 Rapid Proband Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS 6997 Parental Control
QUAD WES TEST OPTIONS
1604 Quad Whole Exome Sequencing 1724 Rapid Quad Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS (Both Biological Parents + One Additional Family Member Are Required) 1550 Comparator WES 1550 Comparator WES Maternal: Half-Sibling, Grandparent, Half-Sibling, Grandparent Paternal: Half-Sibling, Grandparent Second 1550 has Aunt/Unk Aunt/Uncle, First Cousin, First Cousin
ADD-ON TESTS
4900 Global Metabolomic Assisted Pathway Screen - Plasma from EDTA 4901 Global Metabolomic Assisted Pathway Screen - Urine B665 Chromosomal Microarray Analysis (CMA)-HR+SNP Screen (Comprehensive) 2055 Comprehensive mtDNA analysis by NGS 9815 Exome Raw Data Release
Note: Any combination of Chromosomal Microarray Analysis (CMA), mtDNA Analysis, or Global MAPS* can be ordered along with a WES test...
2 // 9 BAYLORGENETICS.COM 03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Patient Last Name
Patient First Name
MI _____
Date of Birth (MM / DD / YYYY)
Genetic Sex
ADDITIONAL REPORTING OPTIONS
If a box is not checked the lab will default to No / Not Report.
Option for Reporting of ACMG Secondary Findings
Variants in genes included in the ACMG secondary findings guidelines will be reported for each family member marked below. Each marked family member will receive their own report on these findings.
B.L.H. 8-17-24
Proband Mother Father Other Family Member
Option for Reporting of Incidental Findings
Pathogenic and likely pathogenic variants in genes covered under Category II of the Incidental Findings section of the consent form will be reported.
Please report pathogenic and likely pathogenic variants in genes associated with Incidental Findings.
Trio and Quad Orders with Both Parents Only – Option for Reporting of Research Findings
For variants in genes with no known disease association, these variants will be reported if biallelic or de novo.
Please report biallelic and de novo variants in genes with no known disease association.
PROBAND SAMPLE(S)
Please refer to www.baylorgenetics.com for full sample requirements.
Blood in EDTA (preferred) Saliva mtDNA analysis only Plasma from EDTA Urine
Buccal Swab Skin Biopsy† Skeletal Muscle Liver Tongue
Cord Blood Extracted DNA from Right leg Tissue Blood # Saliva #
NOTE: Extracted DNA/RNA will only be accepted if the isolation of nucleic acids for clinical testing occurs in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS.
COMPARATOR INFORMATION
| Comparator | Last Name | First Name | Genetic Sex | Date of Birth (MM/DD/YYYY) | Date of Collection (MM/DD/YYYY) | Sample Type | Symptomatic? (Attach summary of findings if Yes) |
|---|---|---|---|---|---|---|---|
| Maternal | Rance | Jill | Female | 01/01/2022 (Handwritten) | 01/24/2022 (Handwritten) |
Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
| Paternal | Rance | Eric | Male | 02/22/1953 (Handwritten) 02/32/1953 (Handwritten) |
03/15/2020 (Handwritten) | Blood in EDTA (preferred) Buccal Swab Saliva |
|
| Other Family Member: | Female Male |
||||||
| Maternal | XXXX/XX/XXXX |
Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
||||
| Paternal |
ITEM CHECKLIST FOR TESTING
Proband Sample (Required) Clinical Note/Summary Pedigree (Optional)
Comparator Samples Requisition
Signed WES Consent Form Indication for Study
† This sample type incurs an additional fee and typically adds 14 days to the turnaround time, depending on sample quality.
† Baylor Genetics will store this sample for up to 14 days after the report is issued, allowing for follow-up testing if needed.
3 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77221-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
Lemon Patient Last Name Farm Patient First Name MI 03 / 05 / 2021 Date of Birth (MM / DD / YYYY) F Genetic Sex
Please provide the following clinical information regarding the patient to be tested. Please also submit a clinic note and pedigree, if available. Phenotypes listed are in HPO terms with the corresponding HPO number (http://human-phenotype-ontology.github.io/). This information is needed to facilitate interpretation of whole exome sequencing results. If the laboratory requires additional information, please indicate the health care provider to be contacted:
- 0001622 Prematurity - GA at birth
- 0001511 Intrauterine Growth Restrictions
- 0001562 Oligohydramnios
- 0001561 Polyhydramnios
- 0000476 Cystic Hygroma
- 0000776 Congenital Diaphragmatic Hernia
- 0001508 Failure to Thrive
- 0001539 Omphalocele
- 0002084 Encephalocele
- 0010880 Increased Nuchal Translucency
- _____
- 0000505 Visual Impairment
- 0000618 Blindness
- 0000589 Coloboma
- 0000526 Aniridia
- 0000528 Anophthalmia
- 0000568 Microphthalmia
- 0000508 Ptosis
- 0000486 Strabismus
- 0000519 Cataract Congenital Bilateral
- _____
- _____
- _____
- 0000750 Delayed Speech & Language Development
- 0001270 Delayed Motor Milestones
- 0002376 Developmental Regression
- Intellectual Disability
- 0001256 Mild
- 0002342 Moderate
- 0010864 Severe
- 0000729 Autistic Spectrum Disorder
- _____
- _____
- _____
- 0001360 Holoprosencephaly
- 0001339 Lissencephaly
- 0002084 Encephalocele
- 0000238 Hydrocephalus
- 0002119 Ventriculomegaly
- 0001273 Abnormality of Corpus Callosum
- 0002539 Cortical Dysplasia
- 0012444 Brain Atrophy
- 0002352 Leukoencephalopathy
- 0002269 Abnormality of Neuronal Migration
- 0002126 Polymicrogyria
- 0001302 Pachgyria
- 0002500 Abnormality of Cerebral White Matter
- 0007266 Cerebral Dysmyelination
- 0006808 Cerebral Hypomyelination
- 0002134 Abnormality of the Basal Ganglia
- 0002363 Abnormality of the Brainstem
- 0007360 Aplasia/Hypoplasia of the Cerebellum
- 0006817 Aplasia/Hypoplasia of the Cerebellar Vermis
- _____
- _____
- 0001284 Areflexia
- 0200134 Epileptic Encephalopathy (marked with handwritten check)
- 0001250 Seizures
- 0002373 Febrile Seizures
- 0012469 Infantile Spasms
- 0002123 Generalized Myoclonic Seizures
- 0002069 Generalized Tonic-clonic Seizures
- 0010818 Generalized Tonic Seizures
- 0010819 Atonic Seizures
- 0002121 Absence Seizures
- 0011169 Generalized Clonic Seizures
- 0001251 Ataxia
- 0001332 Dystonia
- 0002072 Choreia
- 0001257 Spasticity
- 0009830 Neuropathy
- _____
- _____
- 0000256 Macrocephaly
- 0000252 Microcephaly
- 0001363 Craniosynostosis
- 0000204 Cleft Upper Lip
- 0000175 Cleft Palate
- 0000316 Hypertelorism
- 0000601 Hypotelorism
- 0008050 Abnormality of the Palpebral Fissures
- 0000286 Epicanthal Folds
- 0000288 Abnormality of the Philtrum (marked with handwritten check)
- 0010938 Abnormality of the External Nose
- _____
- _____
- _____
Indications continued on next page
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BAYLOGENETICS.COM
03.26.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Patient Last Name
Patient First Name
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
HAIR & SKIN .....
0000957 Cafe-Au-Lait Spots
0001034 Hypermelanotic Macule
0001010 Hypopigmentation of the Skin
0008066 Abnormal Blistering of the Skin
0008064 Ichthyosis
0009988 Skin Rash
0001581 Recurrent Skin Infections
0005306 Capillary Hemangiomas
0001597 Abnormality of the Nail
0004554 Generalized Hypertrichosis
0001596 Alopecia
0002208 Coarse Hair
0002299 Brittle Hair
_____
CARDIAC .....
0001631 Atria Septal Defect
0001629 Ventricular Septal Defect
0001655 Patent Foramen Ovale
0001713 Abnormality of Cardiac Ventricles
0001636 Tetralogy of Fallot
0001680 Coarctation of Aorta
0001647 Bicuspid Aortic Valve
0002616 Aortic Root Dilatation
0001638 Cardiomyopathy
0011675 Arrhythmia
_____
GENITOURINARY .....
0000113 Polycystic Kidney Dysplasia
0000107 Renal Cyst
0008738 Partially Duplicated Kidney
0000104 Renal Agenesis
0000085 Horseshoe Kidney
0000069 Abnormality of the Ureter
0000795 Abnormality of the Urethra
0000047 Hypospadias
0000028 Cryptorchidism
0000035 Abnormality of the Testis
0000062 Ambiguous Genitalia
_____
RESPIRATORY .....
0002093 Respiratory Insufficiency
0002878 Respiratory Failure
0002104 Apnea
0002791 hypoventilation
0002883 Hyperventilation
0002788 Recurrent Upper Respiratory Tract Infections
_____
METABOLIC .....
0001946 Ketosis
0003074 Hyperglycemia
0001943 Hypoglycemia
0001941 Acidosis
0003128 Lactic Acidosis
0003215 Dicarboxylic Aciduria
0002490 Increased CSF lactate
0001992 Organic Aciduria
0030085 Abnormal CSF Lactate Level
00003542 Increased Serum Pyruvate
0003535 3-Methylglutaconic aciduria
0001942 Metabolic acidosis
0100493 Hypoammonemia
0001987 Hyperammonemia
0004923 Hyperphenylalaninemia
0003234 Decreased Plasma Carnitine
0003236 Elevated Serum Creatine Phosphokinase
Abnormal Newborn Screen
Unusual Color/Odor
_____
_____
MUSCULOSKELETAL .....
0011398 Hypotonia
0001276 Hypertonia
0000098 Tall Stature
0004322 Short Stature
0001382 Joint Hypermobility
0001371 Flexion Contracture
0002804 Arthrogyposis Multiplex Congenita
0001164 Hand Polydactyly
0001829 Foot Polydactyly
0006101 Finger Syndactyly
0001770 Toe Syndactyly
0100490 Camptodactyly of Finger
0012165 Oligodactyly
0001762 Talipes Equinovarus
0002757 Recurrent Fractures
0002650 Scoliosis
0002808 Kyphosis
0003307 Hyperlordosis
0001528 Hemihypertrophy
0001513 Obesity
0001548 Overgrowth
0002452 Skeletal Dysplasia
_____
_____
GASTROINTESTINAL .....
0002021 Pyloric Stenosis
0002575 Tracheoesophageal Fistula
0002032 Esophageal Atresia
0002020 Gastroesophageal Reflux
0001733 Pancreatitis
0002014 Diarrhea
0002019 Constipation
0002037 Inflammatory Bowel Disease
0004389 Intestinal Pseudo-Obstruction
0001399 Hepatic Failure
0002572 Episodic Vomiting
0001744 Splenomegaly
0002240 Hepatomegaly
0001508 Postnatal Failure to Thrive
0002578 Gastroparesis
_____
Indications continued on next page
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BAYLORGENETICS.COM
03.24.24
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Patient Last Name
Patient First Name ____ MI
Date of Birth (MM / DD / YYYY)
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
ENDOCRINE .....
- 0000819 Diabetes Mellitus
- 0000873 Diabetes Insipidus
- 0000821 Hypothyroidism
- 0000829 Hypoparathyroidism
- 0000834 Abnormality of the Adrenal Glands
- 0001738 Exocrine Pancreatic Insufficiency
- 0002721 Immunodeficiency
- _____
- _____
HEMATOLOGY .....
- 0001875 Neutropenia
- 0005549 Congenital
Chronic
Cyclic - 0001873 Thrombocytopenia
- 0040185 Macrothrombocytopenia
- 0005537 Decreased Mean Platelet Volume
- 0005518 Erythrocyte Macrocytosis
- 0004444 Spherocytosis
- 0012410 Pure Red Cell Aplasia
Aplastic
Hypoplastic - 0001903 Anemia
- 0005528 Bone Marrow Hypocellularity
- _____
_____
OTHER .....
- Organomegaly
- Chronic Infections
- 0004311 Abnormality of Macrophages
- 0001954 Episodic Fever
- 0004313 Hypogammaglobulinemia
- 0010701 Abnormal Immunoglobulins
- 0002721 Immunodeficiency
- 0012088 Abnormal urinary odor
- 0012537 Food intolerance
- 0008067 Abnormally lax or hyperextensible skin
- Abnormal Movements
- Family History of Similar Disorder
- 00101254 Lethargy
- 0002415 Leukodystrophy
- _____
_____
EAR DEFECTS & HEARING .....
- 0000407 Sensorineural Hearing Impairment
0008619 Bilateral - 0000405 Conductive Hearing Impairment
- 0004410 Mixed Hearing Impairment
- 0004467 Preauricular Pit
- 0000384 Preauricular Skin Tag
- 0000369 Low-set Ears
- 000037 Abnormality of the Pinna
- _____
_____
CANCER .....
- Type of Cancer _____
- Age of Diagnosis _____
- Family History of Cancer and Affected Relatives _____
GENES OF INTEREST .....
ADDITIONAL CLINICAL INFORMATION
DIFFERENTIAL DIAGNOSIS
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Consent on next page
6 // 9
BAYLORGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE EXOME SEQUENCING (WES)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
[Signature]
_____
Patient Last Name
[Signature]
_____
Patient First Name
MI ____
DA / K / MICRO
_____
Date of Birth (MM / DD / YYYY)
[Signature]
_____
Genetic Sex
WHOLE EXOME SEQUENCING (WES) AND WHOLE GENOME SEQUENCING (WGS) CONSENT
This consent form can only be used for whole exome sequencing and whole genome sequencing. Consent forms for other tests are located at Baylor Genetics' website (https://www.baylorgenetics.com/consent/).
For the purposes of this consent, "I", "my", "you", and "your" can refer to you, your child, your unborn child, or other individual you are the legal representative of.
TEST INFORMATION
Your healthcare provider (doctor, genetic counselor, or other person with medical training) wants to order a genetic test called Whole Genome Sequencing (WGS) or Whole Exome Sequencing (WES). These tests look for changes, called variants, in a person's DNA that can cause health issues. DNA is our genetic material. These variants can be in certain genes, specific parts of our DNA that are needed for our health. They can also be found in other places in the genome (all DNA that a person has). Based on your known health issues, variants in your DNA that may cause these issues will be reported. This test may explain your health issues. It may also explain health issues that your family may have. Even if this test finds the cause of your health issues, this may not help treat or manage those issues.
Testing where your DNA is compared to one or more family members may be performed. This may help better understand your results or show if your family members have the same variant as you.
Before you sign this consent form, you should speak with your healthcare provider. They can help you understand this testing and what it means for your health.
TEST RESULTS
There are several types of test results that may be reported including:
- • Positive: A variant in the DNA was found that is related to your health issues or a health issue that you are at an increased risk of having in the future. These changes that cause disease are also known as pathogenic variants.
- • Negative: No variants in the DNA were found that are related to your health issues or that would increase your risk of a health issue in the future.
- • Variant of Uncertain Clinical Significance (VUS): A variant in the DNA was found that we do not know its effect, if any, on health. More testing may be needed for you or your family if a VUS is found that may be associated with your health issues.
- • Secondary and Incidental Findings (Optional): Testing can sometimes find a variant in the DNA not related to the reason for testing but can change your medical care. Note: Certain issues within the brain start in adulthood and get worse over time (neurodegenerative). They often have no cure or treatment. By default, these variants will not be reported unless they are related to your health issues. However, variants in one or more of these gene(s) can be requested if needed. Your provider must write each gene needed in your test order.
- • Genes of No Known Disease Association (Optional): Testing may find a variant in a gene that is not known to cause disease. This may be helpful to learn more about these genes in the future. These results do not currently impact medical management or indicate a diagnosis.
SECONDARY AND INCIDENTAL FINDINGS
The following categories of variants are not expected to cause your current health issues. However, they can each be requested to be reported. Knowing about these variants might affect your future medical care.
- • ACMG Secondary Findings: The American College of Medical Genetics and Genomics (ACMG) recommends reporting disease-causing variants in certain genes that cause health issues. Each family member can request this group of variants to be reported.
- • Incidental Findings: Other variants known to cause health issues but that are not causing your current health issues.
CONSIDERATIONS AND LIMITATIONS
- • You should speak with your provider before signing this consent form to understand the risks, benefits, and alternatives to testing.
- • Testing may show you have, or are at increased chance of having, a health issue. It may show that you have an increased chance of having a child with a health issue.
- • Even if the variant(s) causing your health issues are found, how these issues might progress or improve with treatment might not be known. Affected family members with the same variant might not be affected like you are.
- • Depending on the results of testing, more testing may be needed to understand these results. This testing might be needed for you and/or other family members.
- • A negative result does not rule out the chance for health issues. Our knowledge of variants and how they cause disease may change over time as we learn more about genetics. Testing has limitations to what it can find as well.
- • Certain factors may lead to incorrect results. These include mislabeled samples, incorrect information in the test order, and rare technical errors.
- • More sample may be needed from you if the first sample is not sufficient to complete testing.
USE OF DATA AND SPECIMEN FOR RESEARCH PURPOSES
Biological specimens, test results, and associated information may be used by Baylor Genetics and its research partners for anonymous or coded research purposes, including improving genetic testing, advancing knowledge of genetic conditions, and developing new technologies, including inclusion in de-identified clinical databases, only with the patient's informed consent. Patient data and specimen will not be used for anonymous or coded research, unless authorized by marking below. A patient's decision to decline participation shall not affect their ability to receive testing from Baylor Genetics.
For Oregon patients, please consult the state specific consent form found at www.baylorgenetics.com/forms.
I authorize Baylor Genetics the use of my specimen and de-identified data for research.
FOR SAMPLES FROM NEW YORK STATE RESIDENTS
Samples from New York State residents shall not be included in research without written consent. Samples will not be retained for more than sixty (60) days after receipt by Baylor Genetics, unless authorized by marking below. No tests other than those authorized shall be performed on the samples.
I authorize Baylor Genetics to retain sample(s) longer based on our retention policy for test development, quality assurance, and training purposes.
7 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77201-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE EXOME SEQUENCING (WES)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name: INSU
Patient First Name: _____
MI: _____
Date of Birth (MM / DD / YYYY): 02 / 02 / 1991
Genetic Sex: F
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION
- • If several family members are tested, knowing the correct biological relationships among them is important. In rare cases, testing can show that family members are not related as expected. If this is found, we may contact the provider who ordered your testing.
- • If this testing is requested to be cancelled after the order and sample are sent to the laboratory, please see our Test Cancellation Policy at www.baylorgenetics.com/cancel-test/.
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION (CONTINUED)
- • Only Baylor Genetics and its contracted partners will have access to your sample for the ordered testing. Results from testing will only be released to: (i) a licensed healthcare provider, (ii) those authorized in writing, (iii) the patient or their personal representative, and (iv) those allowed access to test results by law. You have the right to access your test results from Baylor Genetics by providing a written request. You also have the right to request raw data obtained from your sample by providing a written request or HIPAA Authorization Form.
- • In rare cases, people with genetic diseases may have problems with health insurance and employment. The U.S. Federal Government has several laws that prohibit discrimination based on test results by health insurance companies and employers. These laws also prohibit unauthorized disclosure of this information. For more information, please visit www.genome.gov/10092077.
- • Samples will be kept in the laboratory based on our retention policy. Once testing is completed, the de-identified sample may be used for test development, quality assurance, and training purposes. Samples are not returned to patients or providers unless requested prior to testing. You and your heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
- • The information from your testing may be used in scientific research, publications or presentations, but your specific identity will not be revealed. We may contact your provider to obtain more clinical information about you. Baylor Genetics also performs other types of scientific research and may contact you to see if you would like to be involved.
- • Variants found may be submitted to databases. The medical community uses these databases to collect information about how variants might cause disease to improve testing and treatment for patients. An example is ClinVar, a free, public archive of reports on human genetics. Limited clinical information may need to be shared with these databases. In rare cases, this information may be enough to allow you or your family members to be identified.
- • For more information on privacy practices at Baylor Genetics, please visit www.baylorgenetics.com/privacy-practices/.
FINANCIAL AGREEMENT
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. I designate Baylor Genetics as my designated representative for purposes of appealing any denial of benefits by my insurance carrier. I irrevocably assign associated payment to Baylor Genetics, and direct that payment be made directly to Baylor Genetics. Please note, some payers may not cover certain screening tests.
If my health insurer does not cover the test or I do not have health insurance, I have received a good faith estimate of the cost for the genetic testing ordered by my provider and agree to pay for the cost of the genetic testing billed to me by Baylor Genetics based on that good faith estimate. More information is available in Baylor Genetics' No Surprises Act and Good Faith Estimate Notice located at https://www.baylorgenetics.com/no-surprises-act/.
A Medicare Advance Beneficiary Notice (ABN) is required for services Medicare identifies as not medically necessary.
PATIENT AUTHORIZATION
By signing this statement of consent, I acknowledge that I have read, understand, and hereby grant my informed consent for genetic testing. I have received appropriate explanations from my healthcare provider about the planned genetic test(s) and possible results. I have been informed by my healthcare provider about the availability and importance of genetic counseling and have been provided with written information identifying a genetic counselor or medical geneticist who can provide such counseling services. All my questions have been answered, and I have had the necessary time to make an informed decision about the genetic test(s).
Note: If Prenatal WES was ordered, please leave the Patient section blank and complete only a section for each relative tested below.
I hereby give permission to Baylor Genetics to conduct genetic testing as recommended by my healthcare provider.*
| /my name is | /my name is | 04 / 04 / 2026 |
| Patient Name | Patient Signature | Date Signed (MM / DD / YYYY) |
| Relationship to Patient | Name | Signature | Date |
|---|
Relative 1 _____
Relative 2 _____
Relative 3 _____
If one or more family members have a Representative signing on their behalf:
| / / / | / / / | / / / | / / / |
|---|---|---|---|
| Name | Signature | Date (MM / DD / YYYY) | Representative For Relationship to Represented Person(s) |
*If you are signing on behalf of the patient as the parent(s) and/or person with legal authority to act on behalf of the patient or parent, you may be required to provide evidence of your authority.
8 // 9
BAYLORGENETICS.COM
03.24.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE EXOME SEQUENCING (WES)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for:
LONDON FRANK MI 07 / 15 / 1969 F (Gender symbol and name)
Patient Last Name Patient First Name MI Date of Birth (MM / DD / YYYY) Genetic Sex
FOR SURROGATES PREGNANCIES – FOR PRENATAL WES ONLY:
Maternal cell contamination (MCC) studies use blood or another sample from a pregnant person. MCC studies are used to determine that the sample being tested belongs to the fetus and not the pregnant person. The results of MCC studies are not used for the treatment or management of the fetus, pregnant person, or other individuals, and are not part of the pregnant person's designated medical record.
I hereby give permission for my sample to be used for MCC studies:
Surrogate Name _____ .... / .. / .. ___
Surrogate Signature ..... Date Signed (MM / DD / YYYY)
9 // 9
BAYLOGENETICS.COM
03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
A. Ordering Physician Name: Benson Mario
B. Patient Name: Lia Mario
C. Identification Number: NONE
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn't pay for a Baylor Genetics test below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for one or more of the Baylor Genetics test(s) below.
| D. Laboratory Tests | E. Reason Medicare May Not Pay: | F. Estimated Cost |
|---|---|---|
| Duo Whole Exome Sequencing | Medicare does not pay for this test for your condition. | $2,400 |
| Trio Whole Exome Sequencing | $2,400 | |
| Quad Whole Exome Sequencing | $2,400 | |
| Proband WES | $1,800 | |
| Global Metabolomic Assisted Pathway Screen -- Plasma from EDTA | $1,000 | |
| Global Metabolomic Assisted Pathway Screen -- Urine | $1,000 |
WHAT YOU NEED TO DO NOW:
- Read this notice, so you can make an informed decision about your care.
- Ask us any questions that you may have after you finish reading.
- Choose an option below about whether to receive the Baylor Genetics test listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
| G. OPTIONS: Check only one box. We cannot choose a box for you. | ||
|---|---|---|
| OPTION 1. I want the Baylor Genetics Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. | ||
| OPTION 2. I want the Baylor Genetics Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. | ||
| OPTION 3. I don't want the Baylor Genetics Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. | ||
H. Additional Information:
Form CMS-R-131 (Exp.01/31/2026)
Confidential Property of Baylor Genetics
Form Approved OMB No. 0938-0566
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may ask to receive a copy.
I. Signature:
J. Date:
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp.01/31/2026)
Confidential Property of Baylor Genetics
Form Approved OMB No. 0938-0566
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE 1.800.411.4363
FAX 1.800.434.9850
CONNECT
Patient Last Name Curry Patient First Name PJ F Date of Birth (MM / DD / YYYY) 06/06 / 2004
Address 4476 Jointon City Houston State TX Zip 77030 Phone 281-225-1433
Accession # 1012050797016 Hospital / Medical Record #
Genetic Sex:
Female Male Unknown
Gender Identity (If different from above): _____
Ordering Physician DR. CURRY Institution Code HW
Institution Name CHOICE W.C. CURRY
Email (Required for International Clients) 5126513-51397
Phone _____ Fax _____
Name HILARY BLUMESHWарт Name HILARY BLUMESHWART
Email HILARY BLUMESHWART Email HILARY BLUMESHWART
Phone 972-779-0771 / 401 Phone
Fax Fax
Note: Reports will be sent by FAX except for international recipients.
SELF PAYMENT .....
Pay With Sample Bill To Patient
INSTITUTIONAL BILLING .....
| Institution Name | Institution Code | Institution Contact Name | Institution Phone | Institution Contact Email |
INSURANCE .....
Do not perform test until patient is aware of out-of-pocket costs (excludes prenatal testing)
REQUIRED ITEMS 1. Copy of the Front/Back of Insurance Card(s) 2. ICD10 Diagnosis Code(s) ICD10 Diagnosis Code(s) (Required)
3. Name of Ordering Physician 4. Insured Signature of Authorization
Commercial Medicaid Medicare*
*A completed Advance Beneficiary Notice (ABN) is required for Medicare patients that do not meet Medicare criteria.
Has the patient been a hospital inpatient in the last 14 days?
No, the patient was not an inpatient Yes, the patient was an Inpatient (hospital stay longer than 24 hours)
| Primary Insurance Co. Name Allied Compa | Primary Insurance Co. Phone 221-321 | |||
| Primary Member Policy # 0856578990XN473 | Primary Member Group # | |||
| Name of Insured Bar curry | Insured Date of Birth (MM / DD / YYYY) | |||
| Patient's Relationship to Insured BF | Phone of Insured | |||
| Address of Insured 4476 joint blok | ||||
| City Houston | State TX Zip 77030 | |||
| Primary Insurance Co. Name | Secondary Insurance Co. Name | Secondary Insurance Co. Phone | ||
| Secondary Member Policy # | Secondary Member Group # | |||
| Name of Insured | Insured Date of Birth (MM / DD / YYYY) | |||
| Patient's Relationship to Insured | Phone of Insured | |||
| Address of Insured | ||||
| City | State Zip |
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unpaid deductible that the insurance policy dictates. If self-pay is selected, I agree to pay for the cost of testing ordered and billed by Baylor Genetics as outlined in the Good Faith Estimate I received. I understand that I am responsible for sending Baylor Genetics any and all payments that I receive directly from my insurance company in payment for this test. Please note, Medicare may not cover certain screening tests.
Patient / Guardian Printed Name [signature] Patient / Guardian Signature [signature] Date (MM / DD / YYYY) / /
1 // 9 BAYLORGENETICS.COM 03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE 1.800.411.4363
FAX 1.800.434.9850
CONNECT
| Patient Last Name |
Patient First Name |
MI | Date of Birth (MM / DD / YYYY) |
Genetic Sex |
This requisition hereby incorporates the Terms and Conditions of the Laboratory Services found at https://www.baylorgenetics.com/lab-terms-conditions/ or, in the case of international entities, https://www.baylorgenetics.com/terms-conditions-of-the-laboratory-services-international/. This test is medically necessary for the risk assessment, diagnosis, or detection of a disease, illness, impairment, symptom, syndrome, or disorder. The results will determine my patient's medical management and treatment decisions. The person listed as the Ordering Physician is authorized by law to order the test(s) requested herein. I confirm that I have provided genetic testing information to the patient, and they have consented to genetic testing.
Familial samples are required for non-Proband WGS. Please contact the laboratory if placing a test order where the comparator(s) are different than the required family members listed.
For select cases when appropriate as determined by Baylor Genetics, WGS may be supplemented by RNA-Seq and/or Optical Genome Mapping (OGM)* to aid with variant classification and/or result clarification as a standard part of this test offering. If the originally submitted specimen is blood and meets all established specimen requirements, RNA-Seq and/or OGM will be reflexively performed without additional authorization. If these requirements are not met, submission of a new blood specimen may be requested, or reflexive testing may not be performed. A final report will be issued prior to initiating RNA-Seq and/or OGM. Any updates resulting from these additional technologies will be provided through an addended report. Additionally, Long-Read Sequencing (LRS) may be used to confirm certain results.
*OGM and LRS have not yet been approved in New York state and will not be performed on specimens collected there.
1822 Rapid Trio Whole Genome Sequencing
(Both Biological Parents Are Required)
1850 Comparator WGS
Maternal Paternal
1823 Rapid Duo Whole Genome Sequencing
(One Biological Parent Is Required)
1850 Comparator WGS
Maternal Paternal
1829 Rapid Proband Whole Genome Sequencing
Maternal Paternal
1824 Rapid Quad Whole Genome Sequencing
(Both Biological Parents + One Additional Family Member Are Required)
1850 Comparator WGS
Sibling
1850 Comparator WGS
Sibling
Child
4901 Global Metabolomic Assisted Pathway Screen - Urine
Note: Global MAPS® can be ordered along with a genome test, however the turnaround time for results will differ from genome sequencing.
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
Patient Last Name <=u>Jess Patient First Name Erie MI Date of Birth (MM / DD / YYYY) 10 / 12 / 2002 Genetic Sex
If a box is not checked the lab will default to No / Not Report.
Option for Reporting of ACMG Secondary Findings
Variants in genes included in the ACMG secondary findings guidelines will be reported for each family member marked below. Each marked family member will receive their own report on these findings.
Proband Mother Father Other Family Member Mom
Option for Reporting of Incidental Findings
Pathogenic and likely pathogenic variants in genes covered under Category II of the Incidental Findings section of the consent form will be reported.
Yes
KD
No
Please report pathogenic and likely pathogenic variants in genes associated with Incidental Findings.
Trio and Quad Orders with Both Parents Only – Option for Reporting of Research Findings
For variants in genes with no known disease association, these variants will be reported if biallelic or de novo.
Please report biallelic and de novo variants in genes with no known disease association.
Please refer to www.baylordgenetics.com for full sample requirements.
Blood in EDTA (preferred) Saliva
Buccal Swab Skin Biopsy® Card Blood
Cord Blood Extracted DNA from _____
Cultured Skin Fibroblast _____
Global MAPS® only
Plasma from EDTA Urine
____ / ____ / ____
Date of Collection (MM / DD / YYYY)
NOTE: Extracted DNA/RNA will only be accepted if the isolation of nucleic acids for clinical testing occurs in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS.
| Comparator | Last Name | First Name | Genetic Sex | Date of Birth (MM / DD / YYYY) | Date of Collection (MM / DD / YYYY) | Sample Type | Symptomatic? (Attach summary of findings if Yes) |
|---|---|---|---|---|---|---|---|
| Maternal | Jess | Carina | disiapkan 30/12/2021 dx | 10/12/2021 | Blood in EDTA (preferred) Buccal Swab Saliva | Yes No | |
| Paternal | Kim Carla | Carol | 10/11/2022 | Blood in EDTA (preferred) Buccal Swab Saliva | Yes No | ||
| Other Family Member: Sibling Child | Female Male | Yes No |
* This sample type incurs an additional fee and typically adds 14 days to the turnaround time, depending on sample quality.
† Baylor Genetics will store this sample for up to 14 days after the report is issued, allowing for follow-up testing if needed.
3 // 9
BAYLORGENETICS.COM
03.24.26
GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
1.800.411.4363
FAX
1.800.434.9850
Handwritten: BASE [initials] Ape Gi [initials]
Please provide the following clinical information regarding the patient to be tested. Please also submit a clinic note and pedigree, if available. Phenotypes listed are in HPO terms with the corresponding HPO number (http://human-phenotype-ontology.github.io/). This information is needed to facilitate interpretation of whole genome sequencing results. If the laboratory requires additional information, please indicate the health care provider to be contacted:
- 0001622 Prematurity - GA at birth _____
- 0001511 Intrauterine Growth Restrictions _____
- 0001562 Oligohydramnios _____
- 0001561 Polyhydramnios _____
- 0000476 Cystic Hygroma _____
- 0000776 Congenital Diaphragmatic Hernia _____
- 0001508 Failure to Thrive _____
- 0001539 Omphalocele _____
- 0002084 Encephalocele _____
- 0010880 Increased Nuchal Translucency _____
- _____
- 0000505 Visual Impairment _____
- 0000618 Blindness _____
- 0000589 Coloboma _____
- 0000526 Aniridia _____
- 0000528 Anophthalmia _____
- 0000568 Microphthalmia _____
- 0000508 Ptosis _____
- 0000486 Strabismus _____
- 0000519 Cataract Congenital Bilateral _____
- _____
- _____
- 0000750 Delayed Speech & Language Development _____
- 0001270 Delayed Motor Milestones _____
- 0002376 Developmental Regression _____
- Intellectual Disability
- 0001256 Mild _____
- 0002342 Moderate _____
- 0010864 Severe _____
- 0000729 Autistic Spectrum Disorder _____
- _____
- _____
- 0001360 Holoprosencephaly _____
- 0001339 Lissencephaly _____
- 0002084 Encephalocele _____
- 0000238 Hydrocephalus _____
- 0002119 Ventriculomegaly _____
- 0001273 Abnormality of Corpus Callosum _____
- 0002539 Cortical Dysplasia _____
- 0012444 Brain Atrophy _____
- 0002352 Leukoencephalopathy _____
- 0002269 Abnormality of Neuronal Migration _____
- 0002126 Polymicrogyria _____
- 0001302 Pachygyria _____
- 0002500 Abnormality of Cerebral White Matter _____
- 0007266 Cerebral Dysmyelination _____
- 0006808 Cerebral Hypomyelination _____
- 0002134 Abnormality of the Basal Ganglia _____
- 0002363 Abnormality of the Brainstem _____
- 0007360 Aplasia/Hypoplasia of the Cerebellum _____
- 0006817 Aplasia/Hypoplasia of the Cerebellar Vermis _____
- _____
- 0001284 Areflexia _____
- 0200134 Epileptic Encephalopathy _____
- 0001250 Seizures
- 0002373 Febrile Seizures _____
- 0012469 Infantile Spasms _____
- 0002123 Generalized Myoclonic Seizures _____
- 0002069 Generalized Tonic-clonic Seizures _____
- 0010818 Generalized Tonic Seizures _____
- 0010819 Atonic Seizures _____
- 0002121 Absence Seizures _____
- 0011169 Generalized Clonic Seizures _____
- 0001251 Ataxia _____
- 0001332 Dystonia _____
- 0002072 Choreia _____
- 0001257 Spasticity _____
- 0009830 Neuropathy _____
- _____
- _____
- 0000256 Macrocephaly _____
- 0000252 Microcephaly _____
- 0001363 Craniosynostosis _____
- 0000204 Cleft Upper Lip _____
- 0000175 Cleft Palate _____
- 0000316 Hypertelorism _____
- 0000601 Hypotelorism _____
- 0000850 Abnormality of the Palpebral Fissures _____
- 0000286 Epicanthal Folds _____
- 0000288 Abnormality of the Philtrum _____
- 0010938 Abnormality of the External Nose _____
- _____
- _____
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
Icons for Messenger, X, Instagram, Pinterest, and YouTube.
Whole Genome Sequencing (WGS) REQUISITION do / 50 / 2026
Patient Last Name
Patient First Name
MI
Date of Birth (MM / DD / YYYY)
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
HAIR & SKIN
0000957 Cafe-Au-Lait Spots
0001034 Hypermelanotic Macule
0001010 Hypopigmentation of the Skin
0008066 Abnormal Blistering of the Skin
0008064 Ichthyosis
0000988 Skin Rash
0001581 Recurrent Skin Infections
0005306 Capillary Hemangiomas
0001597 Abnormality of the Nail
0004554 Generalized Hypertrichosis
0001596 Alopecia
0002208 Coarse Hair
0002299 Brittle Hair
CARDIAC
0001631 Atrial Septal Defect
0001629 Ventricular Septal Defect
0001655 Patent Foramen Ovale
0001713 Abnormality of Cardiac Ventricle
0001636 Tetralogy of Fallot
0001680 Coarctation of Aorta
0001647 Bicuspid Aortic Valve
0002616 Aortic Root Dilatation
0001638 Cardiomyopathy
0011675 Arrhythmia
GENITOURINARY
0000113 Polycystic Kidney Dysplasia
0000107 Renal Cyst
0008738 Partially Duplicated Kidney
0000104 Renal Agenesis
0000085 Horseshoe Kidney
✓ 0000069 Abnormality of the Ureter
0000795 Abnormality of the Urethra
0000047 Hypospadias
0000028 Cryptorchidism
0000035 Abnormality of the Testis
0000062 Ambiguous Genitalia
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0000195 Fistula between Cervix and Uterine Adh.
0000505 Congenital Genital Abnormalities
0007902 Clinopore Perforation of Scrotum
0000441 Abnormal Inguinal Rings
0000122 Bifid Lumbar Vertebrae
0000887 Undescended Testis
0000199opsy/Procedure/performance
0001987 Undetected Genital Abnormalities
0000198减弱性 Male Pseudohermaphroditism
0000207 Congenital Prepuce Stenosis
0000888 Undetected Genital Abnormalities
0000856 Genitalia Bjerknes Syndrome
0008312 Defect of the Cervical Skin
0000957 Cafe-Au-Lait Spots
0001034 Hypermelanotic Macule
0001010 Hypopigmentation of the Skin
0008066 Abnormal Blistering of the Skin
0008064 Ichthyosis
0000988 Skin Rash
0001581 Recurrent Skin Infections
0005306 Capillary Hemangiomas
0001597 Abnormality of the Nail
0004554 Generalized Hypertrichosis
0001596 Alopecia
0002208 Coarse Hair
0002299 Brittle Hair
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
0001031 Abnormality of the Rectum
0000196 Bulbar Skene's Glands
0000055 Urachal Remnants
0000509 Genital Branches of Femoral Nerve
RESPIRATORY
0002093 Respiratory Insufficiency
0002878 Respiratory Failure
✓ 0002104 Apnea
0002791 Hypoventilation
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE GENOME SEQUENCING (WGS) REQUISITION
Patient Legal Name / Patient First Name / MI / Date of Birth (MM/DD/YYYY) / Gender / Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
ENDOCRINE
- 0000819 Diabetes Mellitus 0000873 Diabetes Insipidus 0000821 Hypothyroidism 0000829 Hypoparathyroidism 0000834 Abnormality of the Adrenal Glands 0001738 Exocrine Pancreatic Insufficiency 0002721 Immunodeficiency
HEMATOLOGY
- 0001875 Neutropenia 0005549 Congenital Chronic Cyclic 0001873 Thrombocytopenia 0040185 Macrothrombocytopenia 0005537 Decreased Mean Platelet Volume 0005518 Erythrocyte Macrocytosis 0004444 Spherocytosis 0012410 Pure Red Cell Aplasia Aplastic Hypoplastic 0001903 Anemia 0005528 Bone Marrow Hypocellularity
OTHER
- Organomegaly Chronic Infections 0004311 Abnormality of Macrophages 0001954 Episodic Fever 0004313 Hypogammaglobulinemia 0010701 Abnormal Immunoglobulins 0002721 Immunodeficiency 0012088 Abnormal urinary odor 0012537 Food intolerance 0008067 Abnormally lax or hyperextensible skin Abnormal Movements Family History of Similar Disorder 0001254 Lethargy 0002415 Leukodystrophy
H-E-A R DEFECTS & HEARING
- 0000407 Sensorineural Hearing Impairment 0008619 Bilateral 0000405 Conductive Hearing Impairment 0000410 Mixed Hearing Impairment 0004467 Preauricular Pit 0000384 Preauricular Skin Tag 0000369 Low-set Ears 000037 Abnormality of the Pinna
CANCER
- Type of Cancer Age of Diagnosis Family History of Cancer and Affected Relatives
GENES OF INTEREST
ADDITIONAL CLINICAL INFORMATION
Empty box for Additional Clinical Information
DIFFERENTIAL DIAGNOSIS
Empty box for Differential Diagnosis
Consent on next page
6 // 9
BAYLOGENETICS.COM
03.26.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4343
FAX
1.800.434.9850
CONNECT
WeChat X Instagram Facebook
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name _____ Patient First Name _____ MI _____ / ___ / ___ Date of Birth (MM / DD / YYYY) _____ Genetic Sex _____
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION
- • If several family members are tested, knowing the correct biological relationships among them is important. In rare cases, testing can show that family members are not related as expected. If this is found, we may contact the provider who ordered your testing.
- • If this testing is requested to be cancelled after the order and sample are sent to the laboratory, please see our Test Cancellation Policy at www.baylorgenetics.com/cancel-test/.
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION (CONTINUED)
- • Only Baylor Genetics and its contracted partners will have access to your sample for the ordered testing. Results from testing will only be released to: (i) a licensed healthcare provider, (ii) those authorized in writing, (iii) the patient or their personal representative, and (iv) those allowed access to test results by law. You have the right to access your test results from Baylor Genetics by providing a written request. You also have the right to request raw data obtained from your sample by providing a written request or HIPAA Authorization Form.
- • In rare cases, people with genetic diseases may have problems with health insurance and employment. The U.S. Federal Government has several laws that prohibit discrimination based on test results by health insurance companies and employers. These laws also prohibit unauthorized disclosure of this information. For more information, please visit www.genome.gov/10002077.
- • Samples will be kept in the laboratory based on our retention policy. Once testing is completed, the de-identified sample may be used for test development, quality assurance, and training purposes. Samples are not returned to patients or providers unless requested prior to testing. You and your heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
- • The information from your testing may be used in scientific research, publications or presentations, but your specific identity will not be revealed. We may contact your provider to obtain more clinical information about you. Baylor Genetics also performs other types of scientific research and may contact you to see if you would like to be involved.
- • Variants found may be submitted to databases. The medical community uses these databases to collect information about how variants might cause disease to improve testing and treatment for patients. An example is ClinVar, a free, public archive of reports on human genetics. Limited clinical information may need to be shared with these databases. In rare cases, this information may be enough to allow you or your family members to be identified.
- • For more information on privacy practices at Baylor Genetics, please visit www.baylorgenetics.com/privacy-practices/.
FINANCIAL AGREEMENT
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. I designate Baylor Genetics as my designated representative for purposes of appealing any denial of benefits by my insurance carrier. I irrevocably assign associated payment to Baylor Genetics, and direct that payment be made directly to Baylor Genetics. Please note, some payers may not cover certain screening tests.
If my health insurer does not cover the test or I do not have health insurance, I have received a good faith estimate of the cost for the genetic testing ordered by my provider and agree to pay for the cost of the genetic testing billed to me by Baylor Genetics based on that good faith estimate. More information is available in Baylor Genetics' No Surprises Act and Good Faith Estimate Notice located at https://www.baylorgenetics.com/no-surprises-act/.
A Medicare Advance Beneficiary Notice (ABN) is required for services Medicare identifies as not medically necessary.
PATIENT AUTHORIZATION
By signing this statement of consent, I acknowledge that I have read, understand, and hereby grant my informed consent for genetic testing. I have received appropriate explanations from my healthcare provider about the planned genetic test(s) and possible results. I have been informed by my healthcare provider about the availability and importance of genetic counseling and have been provided with written information identifying a genetic counselor or medical geneticist who can provide such counseling services. All my questions have been answered, and I have had the necessary time to make an informed decision about the genetic test(s).
Note: If Prenatal WES was ordered, please leave the Patient section blank and complete only a section for each relative tested below.
I hereby give permission to Baylor Genetics to conduct genetic testing as recommended by my healthcare provider.*
_____
/ / /
Patient Name Patient Signature Date Signed (MM / DD / YYYY)
| Relationship to Patient | Name | Signature | Date |
|---|
| Relative 1 |
| Relative 2 |
| Relative 3 |
If one or more family members have a Representative signing on their behalf:
_____
/ / /
Name Signature Date (MM / DD / YYYY) Representative For Relationship to Represented Person(s)
*If you are signing on behalf of the patient as the parent(s) and/or person with legal authority to act on behalf of the patient or parent, you may be required to provide evidence of your authority.
8 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
_____
Patient Last Name _____ PID _____ MI _____ Date of Birth (MM / DD / YYYY) _____ Genetic Sex _____
[Signature] _____ [Signature]
WHOLE EXOME SEQUENCING (WES) AND WHOLE GENOME SEQUENCING (WGS) CONSENT
This consent form can only be used for whole exome sequencing and whole genome sequencing. Consent forms for other tests are located at Baylor Genetics' website (https://www.baylorgenetics.com/consent/).
For the purposes of this consent, "I", "my", "you", and "your" can refer to you, your child, your unborn child, or other individual you are the legal representative of.
TEST INFORMATION
Your healthcare provider (doctor, genetic counselor, or other person with medical training) wants to order a genetic test called Whole Genome Sequencing (WGS) or Whole Exome Sequencing (WES). These tests look for changes, called variants, in a person's DNA that can cause health issues. DNA is our genetic material. These variants can be in certain genes, specific parts of our DNA that are needed for our health. They can also be found in other places in the genome (all DNA that a person has). Based on your known health issues, variants in your DNA that may cause these issues will be reported. This test may explain your health issues. It may also explain health issues that your family may have. Even if this test finds the cause of your health issues, this may not help treat or manage those issues.
Testing where your DNA is compared to one or more family members may be performed. This may help better understand your results or show if your family members have the same variant as you.
Before you sign this consent form, you should speak with your healthcare provider. They can help you understand this testing and what it means for your health.
TEST RESULTS
There are several types of test results that may be reported including:
- • Positive: A variant in the DNA was found that is related to your health issues or a health issue that you are at an increased risk of having in the future. These changes that cause disease are also known as pathogenic variants.
- • Negative: No variants in the DNA were found that are related to your health issues or that would increase your risk of a health issue in the future.
- • Variant of Uncertain Clinical Significance (VUS): A variant in the DNA was found that we do not know its effect, if any, on health. More testing may be needed for you or your family if a VUS is found that may be associated with your health issues.
- • Secondary and Incidental Findings (Optional): Testing can sometimes find a variant in the DNA not related to the reason for testing but can change your medical care.
Note: Certain issues within the brain start in adulthood and get worse over time (neurodegenerative). They often have no cure or treatment. By default, these variants will not be reported unless they are related to your health issues. However, variants in one or more of these gene(s) can be requested if needed. Your provider must write each gene needed in your test order. - • Genes of No Known Disease Association (Optional): Testing may find a variant in a gene that is not known to cause disease. This may be helpful to learn more about these genes in the future. These results do not currently impact medical management or indicate a diagnosis.
SECONDARY AND INCIDENTAL FINDINGS
The following categories of variants are not expected to cause your current health issues. However, they can each be requested to be reported. Knowing about these variants might affect your future medical care.
- • ACMG Secondary Findings: The American College of Medical Genetics and Genomics (ACMG) recommends reporting disease-causing variants in certain genes that cause health issues. Each family member can request this group of variants to be reported.
- • Incidental Findings: Other variants known to cause health issues but that are not causing your current health issues.
CONSIDERATIONS AND LIMITATIONS
- • You should speak with your provider before signing this consent form to understand the risks, benefits, and alternatives to testing.
- • Testing may show you have, or are at increased chance of having, a health issue. It may show that you have an increased chance of having a child with a health issue.
- • Even if the variant(s) causing your health issues are found, how these issues might progress or improve with treatment might not be known. Affected family members with the same variant might not be affected like you are.
- • Depending on the results of testing, more testing may be needed to understand these results. This testing might be needed for you and/or other family members.
- • A negative result does not rule out the chance for health issues. Our knowledge of variants and how they cause disease may change over time as we learn more about genetics. Testing has limitations to what it can find as well.
- • Certain factors may lead to incorrect results. These include mislabeled samples, incorrect information in the test order, and rare technical errors.
- • More sample may be needed from you if the first sample is not sufficient to complete testing.
USE OF DATA AND SPECIMEN FOR RESEARCH PURPOSES
Biological specimens, test results, and associated information may be used by Baylor Genetics and its research partners for anonymous or coded research purposes, including improving genetic testing, advancing knowledge of genetic conditions, and developing new technologies, including inclusion in de-identified clinical databases, only with the patient's informed consent. Patient data and specimen will not be used for anonymous or coded research, unless authorized by marking below. A patient's decision to decline participation shall not affect their ability to receive testing from Baylor Genetics.
For Oregon patients, please consult the state specific consent form found at www.baylorgenetics.com/forms.
I authorize Baylor Genetics the use of my specimen and de-identified data for research [signature]
FOR SAMPLES FROM NEW YORK STATE RESIDENTS
Samples from New York State residents shall not be included in research without written consent. Samples will not be retained for more than sixty (60) days after receipt by Baylor Genetics, unless authorized by marking below. No tests other than those authorized shall be performed on the samples.
I authorize Baylor Genetics to retain sample(s) longer based on our retention policy for test development, quality assurance, and training purposes.
[Signature]
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BAYLOGENETICS.COM
03.24.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVE.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name _____ Patient First Name _____ MI _____ Date of Birth (MM / DD / YYYYY) _____ / _____ / _____ Genetic Sex _____
FOR SURROGATES PREGNANCIES – FOR PRENATAL WES ONLY:
Maternal cell contamination (MCC) studies use blood or another sample from a pregnant person. MCC studies are used to determine that the sample being tested belongs to the fetus and not the pregnant person. The results of MCC studies are not used for the treatment or management of the fetus, pregnant person, or other individuals, and are not part of the pregnant person's designated medical record.
I hereby give permission for my sample to be used for MCC studies
|
Surrogate Name |
Surrogate Signature |
Date Signed (MM / DD / YYYYY) |
9 // 9
03.26.25
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
A. Ordering Physician Name: _____
B. Patient Name: _____
C. Identification Number: _____
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn't pay for a Baylor Genetics test below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for one or more of the Baylor Genetics test(s) below.
| D. Laboratory Tests | E. Reason Medicare May Not Pay: | F. Estimated Cost |
|---|---|---|
| Trio Whole Genome Sequencing | Medicare does not pay for this test for your condition. | $3,500 |
| Duo Whole Genome Sequencing | $3,500 | |
| Proband Whole Genome Sequencing | $3,000 | |
| Quad Whole Genome Sequencing | $6,200 | |
| Global Metabolomic Assisted Pathway Screen – Plasma from EDTA | $1,000 | |
| Global Metabolomic Assisted Pathway Screen-U | $1,000 |
WHAT YOU NEED TO DO NOW:
- Read this notice, so you can make an informed decision about your care.
- Ask us any questions that you may have after you finish reading.
- Choose an option below about whether to receive the Baylor Genetics test listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
| G. OPTIONS: Check only one box. We cannot choose a box for you. | |
|---|---|
| OPTION 1. I want the Baylor Genetics Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. | |
| OPTION 2. I want the Baylor Genetics Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. | |
| OPTION 3. I don't want the Baylor Genetics Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. | |
H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may ask to receive a copy.
| I. Signature: | J. Date: |
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about- us/accessibility-nondiscrimination-notice.
Form CMS-R-131 (Exp.01/31/2026)Confidential Property of Baylor GeneticsForm Approved OMB No. 0938-0566
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
Patient Last Name: Coxen Patient First Name: Frank
Address: 92466 NUMBER DRIVE City: Talent State: WI Zip: 54765 Date of Birth (MM / DD / YYYY): 11 / 11 / 2011
Accession #: _____ Hospital / Medical Record #: _____
Genetic Sex: Female Male Unknown
Gender identity (if different from above): _____
Ordering Physician: Leeza Moren Institution Name: WVX
West Virginia Xian Hospital
Institution Name: West Virginia Xian Hospital Email: twinkleu_xpwr@ WVX.edu
Phone: 338361-9601 Fax: 44977-607008
Additional Reports: Sammy Talent Name: Sammy Talent Email: SMTALENTS.WX.EDU
Spilio Tulo Name: Spilio Tulo Email: SpilioTulo@gravity.com
Phone: 60883679600 Fax: _____
SELF PAYMENT .....
Pay With Sample Bill To Patient
INSTITUTIONAL BILLING .....
Institution Name: UT Wright Pain Hypical Institutional Code: WVX
Institution Contact Name: Tim Withm Institutional Phone: 885048-3607
Institution Contact Email: spolioto@ WVX.CM
No Do not perform test until patient is aware of out-of-pocket costs (excludes prenatal testing)
REQUIRED ITEMS 1. Copy of the Front/Back of Insurance Card(s) 2. ICD10 Diagnosis Code(s) 3. Name of Ordering Physician 4. Insured Signature of Authorization
Commercial Medicaid Medicare*
*A completed Advance Beneficiary Notice (ABN) is required for Medicare patients that do not meet Medicare criteria.
Has the patient been a hospital inpatient in the last 14 days?
No, the patient was not an inpatient Yes, the patient was an inpatient (hospital stay longer than 24 hours)
| Primary Insurance | Secondary Insurance | ||
|---|---|---|---|
| Primary Insurance Co. Name | Primary Insurance Co. Phone | Secondary Insurance Co. Name | Secondary Insurance Co. Phone |
| Primary Member Policy # | Primary Member Group # | Secondary Member Policy # | Secondary Member Group # |
| Name of Insured | Insured Date of Birth (MM / DD / YYYY) | Name of Insured | Insured Date of Birth (MM / DD / YYYY) |
| Patient's Relationship to Insured | Phone of Insured | Patient's Relationship to Insured | Phone of Insured |
| Address of Insured | Address of Insured | ||
| City | State | City | State |
| Zip | Zip | ||
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. If self-pay is selected, I agree to pay for the cost of testing ordered and billed by Baylor Genetics as outlined in the Good Faith Estimate I received. I understand that I am responsible for sending Baylor Genetics any and all payments that I receive directly from my insurance company in payment for this test. Please note, Medicare may not cover certain screening tests.
Patient / Guardian Printed Name _____
Patient / Guardian Signature _____
Date (MM / DD / YYYY) _____
1 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
WHOLE EXOME SEQUENCING (WES) REQUISITION
Casson Thomas _____ M 11/21/2021 M
Patient Last Name Patient First Name MI Date of Birth (MM / DD / YYYY) Genetic Sex
STATEMENT OF MEDICAL NECESSITY AND CONSENT TO TERMS & CONDITIONS FOR TEST ORDER (REQUIRED)
This requisition hereby incorporates the Terms and Conditions of the Laboratory Services found at https://www.baylorgenetics.com/lab-terms-conditions/ or, in the case of international entities, https://www.baylorgenetics.com/terms-conditions-of-the-laboratory-services-international/. This test is medically necessary for the risk assessment, diagnosis, or detection of a disease, illness, impairment, symptom, syndrome, or disorder. The results will determine my patient's medical management and treatment decisions. The person listed as the Ordering Physician is authorized by law to order the test(s) requested herein. I confirm that I have provided genetic testing information to the patient, and they have consented to genetic testing.
Rhu May _____ Thu May _____ 2 / 1 / 2022
Physician's Printed Name Physician's Signature Date (MM / DD / YYYY)
INSTRUCTIONS FOR ORDERING
Familial samples are required for non-Proband WES. Please contact the laboratory if placing a test order where the comparator(s) are different than the required family members listed.
For select cases as determined by Baylor Genetics, WES may be supplemented by RNA-Seq to aid with variant classification as a standard part of this test offering. If the originally submitted specimen is blood and meets all established specimen requirements, RNA-Seq will be reflexively performed without additional authorization. If these requirements are not met, submission of a new blood specimen may be requested, or reflexive testing may not be performed. A final report will be issued prior to initiating RNA-Seq. Any updates resulting from this additional technology will be provided through an addendum report.
TRIO WES TEST OPTIONS
- 1600 Trio Whole Exome Sequencing
- 1722 Rapid Trio Whole Exome Sequencing
- CORRESPONDING COMPARATOR TESTS
- 1550 (Both Biological Parents Are Required)
- 1602 Comparison WES Maternal Paternal
- 1602 WES - Additional Affected Sibling
DUO WES TEST OPTIONS
No bio-MW 1603 Duo Whole Exome Sequencing CORRESPONDING COMPARATOR TESTS 1550
- 1723 Rapid Duo Whole Exome Sequencing (One Biological Parent Is Required) Comparison WES
- Comparison WES
- 1602 WES - Additional Affected Sibling Maternal Paternal
PROBAND WES TEST OPTIONS
- 1500 Proband Whole Exome Sequencing
- 1729 Rapid Proband Whole Exome Sequencing
- CORRESPONDING COMPARATOR TESTS 6997 Parental Control
- 1550 Maternal Paternal
QUAD WES TEST OPTIONS
- 1604 Quad Whole Exome Sequencing
- 1724 Rapid Quad Whole Exome Sequencing
- CORRESPONDING COMPARATOR TESTS
- 1550 (Both Biological Parents + One Additional Family Member Are Required) Comparison WES
- 1550 Paternal Maternal Paternal
- 1550 Mail copies Comparison WES
- Sibling Child Maternal:
- Half-Sibling Aunt/Uncle Grandparent
- First Cousin Paternal:
- Half-Sibling Aunt/Uncle
- Grandparent First Cousin
ADD-ON TESTS
| 4900 Global Metabolomic Assisted Pathway Screen - Plasma from EDTA Was plasma extracted from EDTA? Yes No |
8665 Chromosomal Microarray Analysis (CMA)-HR+SNP Screen (Comprehensive) |
| 4901 Global Metabolomic Assisted Pathway Screen - Urine | 2055 Comprehensive mtDNA analysis by NGS |
| 9815 Exome Raw Data Release |
Note: Any combination of Chromosomal Microarray Analysis (CMA), mtDNA Analysis, or Global MAPS* can be ordered along with a WES test, however the turnaround time for results will differ from exome sequencing.
2 // 9
BAYLORGENETICS.COM
03.26.26
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
1.800.411.4363
FAX
1.800.434.9850
Patient Last Name Czerny Patient First Name Tavia MI M Date of Birth (MM / DD / YYYY) 11 / 11 / 2001 Genetic Sex _____
If a box is not checked the lab will default to No / Not Report.
Option for Reporting of ACMG Secondary Findings
Variants in genes included in the ACMG secondary findings guidelines will be reported for each family member marked below. Each marked family member will receive their own report on these findings.
Proband Mother Father Other Family Member
Option for Reporting of Incidental Findings
Pathogenic and likely pathogenic variants in genes covered under Category II of the Incidental Findings section of the consent form will be reported.
Please report pathogenic and likely pathogenic variants in genes associated with Incidental Findings.
Trio and Quad Orders with Both Parents Only – Option for Reporting of Research Findings
For variants in genes with no known disease association, these variants will be reported if biallelic or de novo.
Please report biallelic and de novo variants in genes with no known disease association.
Please refer to www.baylorgenetics.com for full sample requirements.
|
Blood in EDTA (preferred) Buccal Swab Cord Blood Cultured Skin Fibroblast |
Saliva Skin Biopsy* Extracted DNA from _____ |
mDNA analysis only Skeletal Muscle Liver Tissue |
Global MAPS* only Plasma from EDTA Urine | | Date of Collection (MM / DD / YYYY) |
NOTE: Extracted DNA/RNA will only be accepted if the isolation of nucleic acids for clinical testing occurs in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS.
| Comparator | Last Name | First Name | Genetic Sex | Date of Birth (MM / DD / YYYY) | Date of Collection (MM / DD / YYYY) | Sample Type | Symptomatic? (Attach summary of findings if Yes) |
|---|---|---|---|---|---|---|---|
| Maternal | Czerny | Holly | 01/04/1980 | 01/20/2021 |
Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
|
| Paternal | Czerny | Heath | 01/16/1960 | 03/30/26 |
Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
|
| Other Family Member: Sibling Child Maternal Half-Sibling Aunt/Uncle Grandparent First Cousin |
Female Male _____ |
____ / ____ / ____ | ____ / ____ / ____ |
Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
||
|
Paternal Half-Sibling Aunt/Uncle Grandparent First Cousin |
____ / ____ / ____ | ____ / ____ / ____ |
| Proband Sample (Required) | Clinical Note/Summary | Pedigree (Optional) |
| Comparator Samples | Requisition | |
| Signed WES Consent Form | Indication for Study |
* This sample type incurs an additional fee and typically adds 14 days to the turnaround time, depending on sample quality.
† Baylor Genetics will store this sample for up to 14 days after the report is issued, allowing for follow-up testing if needed.
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Coxen Patient Last Name THOMAS Patient First Name
M MI 11 / 21 / 2011 Date of Birth (MM / DD / YYYY) M Genetic Sex
| INDICATION FOR TESTING (REQUIRED) |
Please provide the following clinical information regarding the patient to be tested. Please also submit a clinic note and pedigree, if available. Phenotypes listed are in HPO terms with the corresponding HPO number (http://human-phenotype-ontology.github.io/). This information is needed to facilitate interpretation of whole exome sequencing results. If the laboratory requires additional information, please indicate the health care provider to be contacted:
|
PRE/PERINATAL HISTORY ..... 0001622 Prematurity - GA at birth 0001511 Intrauterine Growth Restrictions 0001562 Oligohydramnios 0001561 Polyhydramnios 0000476 Cystic Hygroma 0000776 Congenital Diaphragmatic Hernia 0001508 Failure to Thrive 0001539 Omphalocele 0002084 Encephalocele 0010880 Increased Nuchal Translucency |
EYE DEFECTS & VISION ..... 0000505 Visual Impairment 0000618 Blindness 0000589 Coloboma 0000526 Aniridid 0000528 Anophthalmia 0000568 Microphthalmia 0000508 Ptosis 0000486 Strabismus 0000519 Cataract Congenital Bilateral |
MOTOR/COGNITIVE DEVELOPMENT ..... 0000750 Delayed Speech & Language Development 0001270 Delayed Motor Milestones 0002376 Developmental Regression Intellectual Disability 0001256 Mild 0002342 Moderate 0010864 Severe 0000729 Autistic Spectrum Disorder |
|
STRUCTURAL BRAIN ABNORMALITIES ..... 0001360 Holoprosencephaly 0001339 Lissencephaly 0002084 Encephalocele 0000238 Hydrocephalus 0002119 Ventriculomegaly Abnormality of Corpus Callosum 0002539 Cortical Dysplasia 0012444 Brain Atrophy 0002352 Leukoencephalopathy 0002269 Abnormality of Neuronal Migration 0002126 Polymicrogyria 0001302 Pachgyria 0002500 Abnormality of Cerebral White Matter 0007266 Cerebral Dysmyelination 0000808 Cerebral Hypomyelination 0002134 Abnormality of the Basal Ganglia 0002363 Abnormality of the Brainstem 00007360 Aplasia/Hypoplasia of the Cerebellum 0000817 Aplasia/Hypoplasia of the Cerebellar Vermis |
NEUROLOGICAL ..... 0001284 Areflexia 0200134 Epileptic Encephalopathy 0001250 Seizures 0002373 Febrile Seizures 0012469 Infantile Spasms 0002123 Generalized Myoclonic Seizures 0002069 Generalized Tonic-clonic Seizures 0010818 Generalized Tonic Seizures 0010819 Atonic Seizures 0011169 Generalized Clonic Seizures 0001251 Ataxia 0001332 Oystonia 0002072 Choreas 0001257 Spasticity 0009830 Neuropathy |
CRANIOFACIAL ..... 0000256 Macromandible 0000252 Microcephaly 0001363 Craniosynostosis 0000204 Cleft Upper Lip 0000175 Cleft Palate 0000316 Hypotelorism 0000601 Hypotelorism 0008050 Abnormality of the Palpebral Fissures 0000286 Epicanthal Folds 0000288 Abnormality of the Philtrum 0010938 Abnormality of the External Nose |
Indications continued on next page
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BAYLORGENETICS.COM
03.24.20
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Cason ----- Tao ----- Patient Last Name Rhonda ----- M ----- 11/14/20 ----- Date of Birth (MM/YY) [Signature] ----- Geneta [initials]
INDICATION FOR TESTING (REQUIRED) - CONTINUED
HAIR & SKIN -----
0000957 Cafe-Au-Lait Spots
0001034 Hypermelanotic Macule
0001010 Hypopigmentation of the Skin
0008066 Abnormal Blistering of the Skin
0008064 Ichthyosis
0000988 Skin Rash
0001581 Recurrent Skin Infections
0005306 Capillary Hemangiomas
0001597 Abnormality of the Nail
0004554 Generalized Hypertrichosis
0001596 Alopecia
0002208 Coarse Hair
0002299 Brittle Hair
CARDIAC -----
0001631 Atria Septal Defect
0001629 Ventricular Septal Defect
0001655 Patent Foramen Ovale
0001713 Abnormality of Cardiac Ventricle
0001636 Tetralogy of Fallot
0001680 Coarctation of Aorta
0001647 Bicuspid Aortic Valve
0002616 Aortic Root Dilatation
0001638 Cardiomyopathy
0011675 Arrhythmia
GENITOURINARY -----
0000113 Polycystic Kidney Dysplasia
0000107 Renal Cyst
0008738 Partially Duplicated Kidney
0000104 Renal Agenesis
0000085 Horseshoe Kidney
0000069 Abnormality of the Ureter
0000795 Abnormality of the Urethra
0000047 Hypospadias
0000028 Cryptorchidism
0000035 Abnormality of the Testis
0000062 Ambiguous Genitalia
RESPIRATORY -----
0002093 Respiratory Insufficiency
0002878 Respiratory Failure
0002104 Apnea
0002791 Hypoventilation
0002883 Hyperventilation
0002788 Recurrent Upper Respiratory Tract Infections
METABOLIC -----
0001946 Ketosis
0003074 Hyperglycemia
0001943 Hypoglycemia
0001941 Acidosis
0003128 Lactic Acidosis
0003115 Dicarboxylic Aciduria
0002490 Increased CSF lactate
0001992 Organic Aciduria
0030085 Abnormal CSF Lactate Level
00003542 Increased Serum Pyruvate
0003535 3-Methylglutaconic aciduria
0001942 Metabolic acidosis
0100493 Hypoammonemia
0001987 Hyperammonemia
0004923 Hyperphenylalaninemia
0003234 Decreased Plasma Carnitine
0003236 Elevated Serum Creatine Phosphokinase
Abnormal Newborn Screen
MUSCULO SKELETAL -----
0011398 Hypotonia
0001276 Hypertonia
0000098 Tall Stature
0004322 Short Stature
0001382 Joint Hypermobility
0001371 Flexion Contracture
0002804 Arthrogryposis Multiplex Congenita
0001161 Hand Polydactyly
0001829 Foot Polydactyly
0006101 Finger Syndactyly
0001770 Toe Syndactyly
0100490 Camptodactyly of Finger
0012165 Oligodactyly
0001762 Talipes Equinovarus
0002757 Recurrent Fractures
0002650 Scoliosis
0002808 Kyphosis
0003307 Hyperlordosis
0001528 Hemihypertrophy
0001513 Obesity
0001548 Overgrowth
0002652 Skeletal Dysplasia
GASTROINTEGRAL -----
0002021 Pyloric Stenosis
0002575 Tracheoesophageal Fistula
0002032 Esophageal Atresia
0002020 Gastroesophageal Reflux
0001733 Pancreatitis
0002014 Diarrhea
0002019 Constipation
0002037 Inflammatory Bowel Disease
0004389 Intestinal Pseudo-Obstruction
0001399 Hepatic Failure
0002572 Episodic Vomiting
0001744 Splenomegaly
0002240 Hepatomegaly
0001508 Postnatal Failure to Thrive
0002578 Gastroparesis
Signature _____ [Signature]
Indications continued on next page
5 // 9
BAYLORGENETICS.COM
03.24.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Patient Last Name
Patient First Name
Date of Birth Date MM / DD / YYYY
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
ENDOCRINE .....
- 0000819 Diabetes Mellitus
- 0000873 Diabetes Insipidus
- 0000821 Hypothyroidism
- 0000829 Hypoparathyroidism
- 0000834 Abnormality of the Adrenal Glands
- 0001738 Exocrine Pancreatic Insufficiency
- 0002721 Immunodeficiency
- _____
HEMATOLOGY .....
- 0001875 Neutropenia
- 0005549 Congenital
- Chronic
- Cyclic
- 0001873 Thrombocytopenia
- 0040185 Macrothrombocytopenia
- 0005537 Decreased/ Mean Platelet Volume
- 0005518 Erythrocyte Macrocytosis
- 0004444 Spherocytosis
- 0012410 Pure Red Cell Aplasia
- Aplastic
- Hypoplastic
- 0001903 Anemia
- 0005528 Bone Marrow Hypocellularity
- _____
OTHER .....
- Organomegaly
- Chronic Infections
- 0004311 Abnormality of Macrophages
- 0001954 Episodic Fever
- 0004313 Hypogammaglobulinemia
- 0010701 Abnormal Immunoglobulins
- 0002721 Immunodeficiency
- 0012088 Abnormal urinary odor
- 0012537 Food intolerance
- 0008067 Abnormally lax or hyperextensible skin
- Abnormal Movements
- Family History of Similar Disorder
- 0001254 Lethargy
- 0002415 Leukodystrophy
- _____
EAR DEFECTS & HEARING .....
- 0000407 Sensorineural Hearing Impairment
- 0008619 Bilateral
- 0000405 Conductive Hearing Impairment
- 0000410 Mixed Hearing Impairment
- 0004467 Preauricular Pit
- 0000384 Preauricular Skin Tag
- 0000369 Low-set Ears
- 000037 Abnormality of the Pinna
- _____
- CANCER .....
- Type of Cancer _____
- Age of Diagnosis _____
- Family History of Cancer and Affected Relatives _____
GENES OF INTEREST .....
- _____
- _____
- _____
- _____
- _____
ADDITIONAL CLINICAL INFORMATION
DIFFERENTIAL DIAGNOSIS
Consent on next page
6 // 9
BAYLONGENETICS.COM
03.24.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name: Carson Patient First Name: Jesus
Date of Birth: MM / DD / YYYY Genetic Sect: _____
This consent form can only be used for whole exome sequencing and whole genome sequencing. Consent forms for other tests are located at Baylor Genetics' website (https://www.baylorgenetics.com/consent/).
For the purposes of this consent, "I", "my", "you", and "your" can refer to you, your child, your unborn child, or other individual you are the legal representative of.
Your healthcare provider (doctor, genetic counselor, or other person with medical training) wants to order a genetic test called Whole Genome Sequencing (WGS) or Whole Exome Sequencing (WES). These tests look for changes, called variants, in a person's DNA that can cause health issues. DNA is our genetic material. These variants can be in certain genes, specific parts of our DNA that are needed for our health. They can also be found in other places in the genome (all DNA that a person has). Based on your known health issues, variants in your DNA that may cause these issues will be reported. This test may explain your health issues. It may also explain health issues that your family may have. Even if this test finds the cause of your health issues, this may not help treat or manage those issues.
Testing where your DNA is compared to one or more family members may be performed. This may help better understand your results or show if your family members have the same variant as you.
Before you sign this consent form, you should speak with your healthcare provider. They can help you understand this testing and what it means for your health.
There are several types of test results that may be reported including:
- • Positive: A variant in the DNA was found that is related to your health issues or a health issue that you are at an increased risk of having in the future. These changes that cause disease are also known as pathogenic variants.
- • Negative: No variants in the DNA were found that are related to your health issues or that would increase your risk of a health issue in the future.
- • Variant of Uncertain Clinical Significance (VUS): A variant in the DNA was found that we do not know its effect, if any, on health. More testing may be needed for you or your family if a VUS is found that may be associated with your health issues.
- • Secondary and Incidental Findings (Optional): Testing can sometimes find a variant in the DNA not related to the reason for testing but can change your medical care. Note: Certain issues within the brain start in adulthood and get worse over time (neurodegenerative). They often have no cure or treatment. By default, these variants will not be reported unless they are related to your health issues. However, variants in one or more of these gene(s) can be requested if needed. Your provider must write each gene needed in your test order.
- • Genes of No Known Disease Association (Optional): Testing may find a variant in a gene that is not known to cause disease. This may be helpful to learn more about these genes in the future. These results do not currently impact medical management or indicate a diagnosis.
The following categories of variants are not expected to cause your current health issues. However, they can each be requested to be reported. Knowing about these variants might affect your future medical care.
- • ACMG Secondary Findings: The American College of Medical Genetics and Genomics (ACMG) recommends reporting disease-causing variants in certain genes that cause health issues. Each family member can request this group of variants to be reported.
- • Incidental Findings: Other variants known to cause health issues but that are not causing your current health issues.
- • You should speak with your provider before signing this consent form to understand the risks, benefits, and alternatives to testing.
- • Testing may show you have, or are at increased chance of having, a health issue. It may show that you have an increased chance of having a child with a health issue.
- • Even if the variant(s) causing your health issues are found, how these issues might progress or improve with treatment might not be known. Affected family members with the same variant might not be affected like you are.
- • Depending on the results of testing, more testing may be needed to understand these results. This testing might be needed for you and/or other family members.
- • A negative result does not rule out the chance for health issues. Our knowledge of variants and how they cause disease may change over time as we learn more about genetics. Testing has limitations to what it can find as well.
- • Certain factors may lead to incorrect results. These include mislabeled samples, incorrect information in the test order, and rare technical errors.
- • More sample may be needed from you if the first sample is not sufficient to complete testing.
Biological specimens, test results, and associated information may be used by Baylor Genetics and its research partners for anonymous or coded research purposes, including improving genetic testing, advancing knowledge of genetic conditions, and developing new technologies, including inclusion in de-identified clinical databases, only with the patient's informed consent. Patient data and specimen will not be used for anonymous or coded research, unless authorized by marking below. A patient's decision to decline participation shall not affect their ability to receive testing from Baylor Genetics.
For Oregon patients, please consult the state specific consent form found at www.baylorgenetics.com/forms.
I authorize Baylor Genetics the use of my specimen and de-identified data for research.
Samples from New York State residents shall not be included in research without written consent. Samples will not be retained for more than sixty (60) days after receipt by Baylor Genetics, unless authorized by marking below. No tests other than those authorized shall be performed on the samples.
I authorize Baylor Genetics to retain sample(s) longer based on our retention policy for test development, quality assurance, and training purposes.
7 // 9
BAYLORGENETICS.COM
03.24.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name Patient First Name MI Date of Birth (MM / DD / YYYY) Genetic Sex
- • If several family members are tested, knowing the correct biological relationships among them is important. In rare cases, testing can show that family members are not related as expected. If this is found, we may contact the provider who ordered your testing.
- • If this testing is requested to be cancelled after the order and sample are sent to the laboratory, please see our Test Cancellation Policy at www.baylorgenetics.com/cancel-test/.
- • Only Baylor Genetics and its contracted partners will have access to your sample for the ordered testing. Results from testing will only be released to: (i) a licensed healthcare provider, (ii) those authorized in writing, (iii) the patient or their personal representative, and (iv) those allowed access to test results by law. You have the right to access your test results from Baylor Genetics by providing a written request. You also have the right to request raw data obtained from your sample by providing a written request or HIPAA Authorization Form.
- • In rare cases, people with genetic diseases may have problems with health insurance and employment. The U.S. Federal Government has several laws that prohibit discrimination based on test results by health insurance companies and employers. These laws also prohibit unauthorized disclosure of this information. For more information, please visit www.genome.gov/10002077.
- • Samples will be kept in the laboratory based on our retention policy. Once testing is completed, the de-identified sample may be used for test development, quality assurance, and training purposes. Samples are not returned to patients or providers unless requested prior to testing. You and your heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
- • The information from your testing may be used in scientific research, publications or presentations, but your specific identity will not be revealed. We may contact your provider to obtain more clinical information about you. Baylor Genetics also performs other types of scientific research and may contact you to see if you would like to be involved.
- • Variants found may be submitted to databases. The medical community uses these databases to collect information about how variants might cause disease to improve testing and treatment for patients. An example is ClinVar, a free, public archive of reports on human genetics. Limited clinical information may need to be shared with these databases. In rare cases, this information may be enough to allow you or your family members to be identified.
- • For more information on privacy practices at Baylor Genetics, please visit www.baylorgenetics.com/privacy-practices/.
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. I designate Baylor Genetics as my designated representative for purposes of appealing any denial of benefits by my insurance carrier. I irrevocably assign associated payment to Baylor Genetics, and direct that payment be made directly to Baylor Genetics. Please note, some payers may not cover certain screening tests.
If my health insurer does not cover the test or I do not have health insurance, I have received a good faith estimate of the cost for the genetic testing ordered by my provider and agree to pay for the cost of the genetic testing billed to me by Baylor Genetics based on that good faith estimate. More information is available in Baylor Genetics' No Surprises Act and Good Faith Estimate Notice located at https://www.baylorgenetics.com/no-surprises-act/.
A Medicare Advance Beneficiary Notice (ABN) is required for services Medicare identifies as not medically necessary.
By signing this statement of consent, I acknowledge that I have read, understand, and hereby grant my informed consent for genetic testing. I have received appropriate explanations from my healthcare provider about the planned genetic test(s) and possible results. I have been informed by my healthcare provider about the availability and importance of genetic counseling and have been provided with written information identifying a genetic counselor or medical geneticist who can provide such counseling services. All my questions have been answered, and I have had the necessary time to make an informed decision about the genetic test(s).
Note: If Prenatal WES was ordered, please leave the Patient section blank and complete only a section for each relative tested below.
I hereby give permission to Baylor Genetics to conduct genetic testing as recommended by my healthcare provider.
Patient Name Patient Signature Date Signed (MM / DD / YYYY)
| Relationship to Patient | Name | Signature | Date |
|---|---|---|---|
| Relative 1 | |||
| Relative 2 | |||
| Relative 3 |
If one or more family members have a Representative signing on their behalf:
Name Signature Date (MM / DD / YYYY) Representative For Relationship to Represented Person(s)
*If you are signing on behalf of the patient as the parent(s) and/or person with legal authority to act on behalf of the patient or parent, you may be required to provide evidence of your authority.
8 // 9
BAYLORGENETICS.COM
03.24.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
_____
Patient Last Name Patient First Name MI _____ / _____ / _____
Date of Birth (MM / DD / YYYY) Genetic Sex
FOR SURROGATES PREGNANCIES - FOR PRENATAL WES ONLY:
Maternal cell contamination (MCC) studies use blood or another sample from a pregnant person. MCC studies are used to determine that the sample being tested belongs to the fetus and not the pregnant person. The results of MCC studies are not used for the treatment or management of the fetus, pregnant person, or other individuals, and are not part of the pregnant person's designated medical record.
I hereby give permission for my sample to be used for MCC studies:
_____
Surrogate Name Surrogate Signature _____ / _____ / _____
Date Signed (MM / DD / YYYY)
9 // 9 BAYLORGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
A. Ordering Physician Name: _____
B. Patient Name: _____
C. Identification Number: _____
_____
NOTE: If Medicare doesn't pay for a Baylor Genetics test below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for one or more of the Baylor Genetics test(s) below.
| D. Laboratory Tests | E. Reason Medicare May Not Pay: | F. Estimated Cost |
|---|---|---|
| Duo Whole Exome Sequencing | Medicare does not pay for this test for your condition. | $2,400 |
| Trio Whole Exome Sequencing | $2,400 | |
| Quad Whole Exome Sequencing | $2,400 | |
| Proband WES | $1,800 | |
| Global Metabolomic Assisted Pathway Screen – Plasma from EDTA | $1,000 | |
| Global Metabolomic Assisted Pathway Screen – Urine | $1,000 |
WHAT YOU NEED TO DO NOW:
- • Read this notice, so you can make an informed decision about your care.
- • Ask us any questions that you may have after you finish reading.
- • Choose an option below about whether to receive the Baylor Genetics test listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
| G. OPTIONS: Check only one box. We cannot choose a box for you. | |
| OPTION 1. I want the Baylor Genetics Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. | |
| OPTION 2. I want the Baylor Genetics Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. | |
| OPTION 3. I don't want the Baylor Genetics Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. | |
H. Additional Information:
Form CMS-R-131 (Exp.01/31/2026)
Confidential Property of Baylor Genetics
Form Approved OMB No. 0938-0586
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may ask to receive a copy.
| I. Signature | J. Date: 02/20/2006 |
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp.01/31/2026)
Confidential Property of Baylor Genetics
Form Approved OMB No. 0938-0566
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
Patient Last Name: Tully
Patient First Name: Carlton MI: ___
Address: 23091 Robert Palmery Richison TX 77440 Date of Birth (MM / DD / YYYY): 07/07/1980 1908
38328846680
Acellion #: ___ City: ___ Phone: ___
Hospital / Medical Record #: ___ State: Texas Zip: 77440
Genetic Sex: Female Male Unknown
Gender identity (if different from above): ___
Note: All reports will be sent via fax except for international recipients.
Ordering Physician: Stewart Giac Institution Code: TX - OHTP
Institution Name: CX Turner Peak
Email (Required for International Clients): 805-690-III
Phone: ___ Fax: ___
Name: Bethany Meyerson
Email: Bethany.Meyerson@baylor.edu Note: Reports will be sent by FAX except for international recipients
Phone: ___ Fax: ___
Phone: ___ Fax: ___
SELF PAYMENT .....
Pay With Sample Bill To Patient
INSTITUTIONAL BILLING .....
| Institution Name | Institution Code | Institution Contact Name | Institution Phone | Institution Contact Email |
|---|
INSURANCE .....
Do not perform test until patient is aware of out-of-pocket costs (excludes prenatal testing)
REQUIRED ITEMS 1. Copy of the Front/Back of Insurance Card(s) 2. ICD10 Diagnosis Code(s)
3. Name of Ordering Physician 4. Insured Signature of Authorization (Located below this section). _____ ICD10 Diagnosis Code(s) (Required)
_____
Commercial Medicaid Medicare*
*A completed Advance Beneficiary Notice (ABN) is required for Medicare patients that do not meet Medicare criteria.
Has the patient been a hospital inpatient in the last 14 days?
No, the patient was not an inpatient Yes, the patient was an inpatient (hospital stay longer than 24 hours)
Primary Insurance Co. Name: _____ Primary Insurance Co. Phone: ____
Primary Member Policy #: _____ Primary Member Group #: ____
___/___/___ Insured Date of Birth (MM / DD / YYYY)
Name of Insured: _____
Patient's Relationship to Insured: _____ Phone of Insured: _____
Address of Insured: _____
City: _____ State: _____ Zip: _____
Secondary Insurance Co. Name: _____ Secondary Insurance Co. Phone: ____
Secondary Member Policy #: _____ Secondary Member Group #: ____
___/___/___ Insured Date of Birth (MM / DD / YYYY)
Name of Insured: _____
Patient's Relationship to Insured: _____ Phone of Insured: _____
Address of Insured: _____
City: _____ State: _____ Zip: _____
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. If self-pay is selected, I agree to pay for the cost of testing ordered and billed by Baylor Genetics as outlined in the Good Faith Estimate I received. I understand that I am responsible for sending Baylor Genetics any and all payments that I receive directly from my insurance company in payment for this test. Please note, Medicare may not cover certain screening tests.
Patient / Guardian Printed Name
Patient / Guardian Signature
Date (MM / DD / YYYY)
07/21/2022
1 / / 9
BAYLORGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
C
CONNECT
Patient Last Name
Patient First Name
Date of Birth (MM / DD / YYY)
Genetic Sex
This requisition hereby incorporates the Terms and Conditions of the Laboratory Services found at https://www.baylorgenetics.com/lab-terms-conditions/ or, in the case of international entities, https://www.baylorgenetics.com/terms-conditions-of-the-laboratory-services-international/. This test is medically necessary for the risk assessment, diagnosis, or detection of a disease, illness, impairment, symptom, syndrome, or disorder. The results will determine my patient's medical management and treatment decisions. The person listed as the Ordering Physician is authorized by law to order the test(s) requested herein. I confirm that I have provided genetic testing information to the patient, and they have consented to genetic testing.
Physician's Printed Name
Physician's Signature
Date (MM / DD / YYY)
Familial samples are required for non-Proband WGS. Please contact the laboratory if placing a test order where the comparator(s) are different than the required family members listed.
For select cases when appropriate as determined by Baylor Genetics, WGS may be supplemented by RNA-Seq and/or Optical Genome Mapping (OGM)* to aid with variant classification and/or result clarification as a standard part of this test offering. If the originally submitted specimen is blood and meets all established specimen requirements, RNA-Seq and/or OGM will be reflexively performed without additional authorization. If these requirements are not met, submission of a new blood specimen may be requested, or reflexive testing may not be performed. A final report will be issued prior to initiating RNA-Seq and/or OGM. Any updates resulting from these additional technologies will be provided through an addendum. Additionally, Long-Read Sequencing (LRS) may be used to confirm certain results.
*OGM and LRS have not yet been approved in New York state and will not be performed on specimens collected there.
1822 Rapid Trio Whole Genome Sequencing
(Both Biological Parents Are Required)
1850 Comparator WGS
Maternal Paternal
1823 Rapid Duo Whole Genome Sequencing
(One Biological Parent Is Required)
1850 Comparator WGS
Maternal Paternal
1829 Rapid Proband Whole Genome Sequencing
6997 Comparator Control
Maternal Paternal
1824 Rapid Quad Whole Genome Sequencing
(Both Biological Parents + One Additional Family Member Are Required)
1850 Comparator WGS
Maternal Paternal
1850 Comparator WGS
Sibling Child
Maternal: Half-Sibling Aunt/Uncle
Grandparent First Cousin
Paternal: Half-Sibling Aunt/Uncle
Grandparent First Cousin
4901 Global Metabolomic Assisted Pathway Screen - Urine
Yes No
Note: Global MAPS® can be ordered along with a genome test, however the turnaround time for results will differ from genome sequencing.
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
WHOLE GENOME SEQUENCING (WGS) REQUISITION
Trinity
Patient Last Name
Cole
Patient First Name
MI
02/02/1908
Date of Birth (MM / DD / YYYY)
M
Genetic Sex
ADDITIONAL REPORTING OPTIONS
If a box is not checked the lab will default to No / Not Report.
Option for Reporting of ACMG Secondary Findings
Variants in genes included in the ACMG secondary findings guidelines will be reported for each family member marked below. Each marked family member will receive their own report on these findings.
Proband Mother Father Other Family Member
Option for Reporting of Incidental Findings
Pathogenic and likely pathogenic variants in genes covered under Category II of the Incidental Findings section of the consent form will be reported.
Please report pathogenic and likely pathogenic variants in genes associated with Incidental Findings.
Trio and Quad Orders with Both Parents Only – Option for Reporting of Research Findings
For variants in genes with no known disease association, these variants will be reported if biallelic or de novo.
Please report biallelic and de novo variants in genes with no known disease association.
PROBAND SAMPLE(S)
Please refer to www.baylorgenetics.com for full sample requirements.
Blood in EDTA (preferred) Saliva
Buccal Swab Skin Biopsy*
Cord Blood Extracted DNA from _____
Cultured Skin Fibroblast
Global MAPS* only
Plasma from EDTA Urine
MM / DD / YYYY
Date of Collection (MM / DD / YYYY)
NOTE: Extracted DNA/RNA will only be accepted if the isolation of nucleic acids for clinical testing occurs in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS.
COMPARATOR INFORMATION
| Comparator | Last Name | First Name | Genetic Sex | Date of Birth (MM / DD / YYYY) | Date of Collection (MM / DD / YYYY) | Sample Type | Symptomatic? (Attach summary of findings if Yes) |
|---|---|---|---|---|---|---|---|
| Maternal | Curtis | Maria | [Hatched area] | 11/05/1860 | 11/20/2020 |
Blood in EDTA (preferred) Buccal Swab |
Yes No |
| Paternal | Curtis | Matthew | 10/02/1880 | 11/20/2020 |
Blood in EDTA (preferred) Buccal Swab |
Yes No |
|
| Other Family Member: Sibling Child |
Female Male |
||||||
| Maternal Half-Sibling Aunt/Uncle Grandparent First Cousin |
____/____/_____ | ____/____/_____ |
Blood in EDTA (preferred) Buccal Swab |
Yes No |
|||
| Paternal Half-Sibling Aunt/Uncle Grandparent First Cousin |
* This sample type incurs an additional fee and typically adds 14 days to the turnaround time, depending on sample quality.
† Baylor Genetics will store this sample for up to 14 days after the report is issued, allowing for follow-up testing if needed.
3 // 9
BAYLORGENETICS.COM
03.26.26
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
1.800.411.4363
FAX
1.800.434.9850
07/19/19
| Patient Last Name | Patient First Name | MI | Date of Birth (MM / DD / YYYY) | Genetic Sex |
Proband Sample (Required)
Clinical Note/Summary
Pedigree (optional)
Comparator Samples
Requisition
Signed WGS Consent Form
Indication for Study
Please provide the following clinical information regarding the patient to be tested. Please also submit a clinic note and pedigree, if available. Phenotypes listed are in HPO terms with the corresponding HPO number (http://human-phenotype-ontology.github.io/). This information is needed to facilitate interpretation of whole genome sequencing results. If the laboratory requires additional information, please indicate the health care provider to be contacted:
| PRE/PERINATAL HISTORY | EYE DEFECTS & VISION | MOTOR/COGNITIVE DEVELOPMENT |
|
0001622 Prematurity - GA at birth 0001511 Intrauterine Growth Restrictions 0001562 Oligohydramnios 0001561 Polyhydramnios 0000476 Cystic Hygroma 0000776 Congenital Diaphragmatic Hernia 0001508 Failure to Thrive (arrow) 0001539 Omphalocele (arrow) 0002084 Encephalocele (arrow) 0010880 Increased Nuchal Translucency _____ |
0000505 Visual Impairment 0000618 Blindness 0000589 Coloboma 0000526 Aniridia 0000528 Anophthalmia 0000568 Microphthalmia 0000508 Ptois 0000486 Strabismus (arrow) 0000519 Cataract Congenital Bilateral _____ _____ |
0000750 Delayed Speech & Language Development 0001270 Delayed Motor Milestones 0002376 Developmental Regression Intellectual Disability 0001256 Mild 0002342 Moderate 0010864 Severe 0000729 Autistic Spectrum Disorder _____ _____ |
| STRUCTURAL BRAIN ABNORMALITIES | NEUROLOGICAL | CRANIOFACIAL |
|
0001360 Holoprosencephaly 0001339 Lissencephaly 0002084 Encephalocele 0000238 Hydrocephalus 0002119 Ventriculomegaly 0001273 Abnormality of Corpus Callosum 0002539 Cortical Dysplasia 0012444 Brain Atrophy 0002352 Leukoencephalopathy 0002269 Abnormality of Neuronal Migration 0002126 Polymicrogyria Pachgyria (arrow) 0002500 Abnormality of Cerebral White Matter 0007266 Cerebral Dysmyelination 0006808 Cerebral Hypomyelination 0002134 Abnormality of the Basal Ganglia 0002363 Abnormality of the Brainstem 0007360 Aplasia/Hypoplasia of the Cerebellum 0006817 Aplasia/Hypoplasia of the Cerebellar Vermis _____ |
0001284 Areflexia (arrow) 0200134 Epileptic Encephalopathy 0001250 Seizures 0002373 Febrile Seizures 0012469 Infantile Spasms 0002123 Generalized Myoclonic Seizures 0002069 Generalized Tonic-clonic Seizures 0010818 Generalized Tonic Seizures 0010819 Atonic Seizures 0002121 Absence Seizures 0011169 Generalized Clonic Seizures 0001251 Ataxia 0001332 dystonia 0002077 chorea 0001257 Spasticity 0009830 Neuropathy _____ _____ |
0000256 Macrocephaly 0000252 Microcephaly 0001363 Craniosynostosis 0000204 Cleft Upper Lip 0000175 Cleft Palate 0003016 Hypertelorism (arrow) 0000601 Hypotelorism 0000805 Abnormality of the Palpebral Fissures 0000288 Epicanthal Folds 0000288 Abnormality of the Philtrum 0010938 Abnormality of the External Nose _____ _____ |
Indications continued on next page
4 / 9 BAYLORGENETICS.COM 03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE 1.800.411.4363
FAX 1.800.434.9850
CONNECT
WHOLE GENOME SEQUENCING (WGS) REQUISITION
| Patient Last Name _____ | Patient First Name _____ | MI _____ | Date of Birth (MM / DD / YYYY) _____ / ____ / ____ | Genetic Sex _____ |
INDICATION FOR TESTING (REQUIRED) - CONTINUED
HAIR & SKIN .....
- 0000957 Cafe-Au-Lait Spots
- 0001034 Hypermelanotic Macule
- 0001010 Hypopigmentation of the Skin →
- 0008066 Abnormal Blistering of the Skin
- 0008064 Ichthyosis
- 0000988 Skin Rash
- 0001581 Recurrent Skin Infections
- 0005306 Capillary Hemangiomas
- 0001597 Abnormality of the Nail
- 0004554 Generalized Hypertrichosis
- 0001596 Alopecia
- 0002208 Coarse Hair
- 0002299 Brittle Hair
- _____
- _____
- _____
- _____
- _____
CARDIAC .....
- 0001631 Atrial Septal Defect
- 0001629 Ventricular Septal Defect
- 0001655 Patent Foramen Ovale
- 0001713 Abnormality of Cardiac Ventricle
- 0001636 Tetralogy of Fallot
- 0001680 Coarctation of Aorta
- 0001647 Bicuspid Aortic Valve
- 0002616 Aortic Root Dilation
- 0001638 Cardiomyopathy
- 0011675 Arrhythmia
- _____
- _____
- _____
- _____
- _____
- _____
- _____
GENITOURINARY .....
- 0000113 Polycystic Kidney Dysplasia
- 0000107 Renal Cyst
- 0008738 Partially Duplicated Kidney
- 0000104 Renal Agenesis
- 0000085 Horseshoe Kidney
- 0000069 Abnormality of the Ureter
- 0000795 Abnormality of the Urethra
- 0000047 Hypospadias
- 0000028 Cryptorchidism
- 0000035 Abnormality of the Testis
- 0000062 Ambiguous Genitalia
- _____
- _____
- _____
- _____
- _____
- _____
- _____
RESPIRATORY .....
- 0002093 Respiratory Insufficiency
- 0002878 Respiratory Failure
- 0002104 Apnea
- 0002791 Hypoventilation
- 0002883 Hyperventilation
- 0002788 Recurrent Upper Respiratory Tract Infections
- _____
- _____
- _____
- _____
- _____
- _____
- _____
- _____
- _____
- _____
- _____
- _____
METABOLIC .....
- 0001946 Ketoacidosis
- 0003074 Hyperglycemia
- 0001943 Hypoglycemia
- 0001941 Acidosis
- 0003128 Lactic Acidosis
- 0003215 Dicarboxylic Aciduria
- 0002490 Increased CSF Lactate
- 0001992 Organic Aciduria
- 0003085 Abnormal CSF Lactate Level
- 00003542 Increased Serum Pyruvate
- 0003535 3-Methylglutaconic aciduria
- 0001942 Metabolic acidosis
- 0100493 Hypoammonemia
- 0001987 Hyperammonemia
- 0004923 Hyperphenylalaninemia
- 0003234 Decreased Plasma Carnitine
- 0003236 Elevated Serum Creatine Phosphokinase
- Abnormal Newborn Screen
- Unusual Color/Odor
- Spots
- _____
- _____
- _____
- _____
- _____
- _____
MUSCULOSKELETAL .....
- 0011398 Hypotonia
- 0001276 Hypertonia
- 0000098 Tall Stature
- 0004322 Short Stature
- 0001382 Joint Hypermobility
- 0001371 Flexion Contracture
- 0002804 Arthrogyposis Multiplex Congenita
- 0001161 Hand Polydactyly
- 0001829 Foot Polydactyly
- 0006101 Finger Syndactyly
- 0001770 Toe Syndactyly
- 0100490 Camptodactyly of Finger
- 0012165 Oligodactyly
- 0001762 Talipes Equinovarus
- 0002757 Recurrent Fractures
- 0002650 Scoliosis
- 0002808 Kyphosis
- 0003307 Hyperlordosis
- 0001528 Hemihypertrophy
- 0001513 Obesity
- 0001548 Overgrowth
- 0002652 Skeletal Dysplasia
- _____
- _____
- _____
- _____
- _____
- _____
- _____
Indications continued on next page
5 // 9
BAYLORGENETICS.COM
03.24.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE GENOME SEQUENCING (WGS) REQUISITION
Caden
Patient Last Name
Tianny
Patient First Name
MI
01/01/2022
Date of Birth (MM / DD / YYYY)
Male
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
| ENDOCRINE ..... | HEMATOLOGY ..... | OTHER ..... |
|---|---|---|
|
0000819 Diabetes Mellitus 0000873 Diabetes Insipidus 0000821 Hypothyroidism 0000829 Hypoparathyroidism 0000834 Abnormality of the Adrenal Glands 0001738 Exocrine Pancreatic Insufficiency 0002721 Immunodeficiency _____ _____ |
0001875 Neutropenia 0005549 Congenital Chronic Cyclic 0001873 Thrombocytopenia 0040185 Macrothrombocytopenia 0005537 Decreased Mean Platelet Volume 0005518 Erythrocyte Macrocytosis 0004444 Spherocytosis 0012410 Pure Red Cell Aplasia Aplastic Hypoplastic 0001903 Anemia 0005528 Bone Marrow Hypocellularity _____ _____ |
Organomegaly Chronic Infections 0004311 Abnormality of Macrophages 0001954 Episodic Fever 0004313 Hypogammaglobulinemia 0010701 Abnormal Immunoglobulins 0002721 Immunodeficiency 0012088 Abnormal urinary odor 0012537 Food intolerance 0008067 Abnormally lax or hyperextensible skin Abnormal Movements Family History of Similar Disorder 0001254 Lethargy 0002415 Leukodystrophy _____ _____ |
|
EAR DEFECTS & HEARING ..... 0000407 Sensorineural Hearing Impairment 0008619 Bilateral 0000405 Conductive Hearing Impairment 0000410 Mixed Hearing Impairment 0004467 Preauricular Pit 0000384 Preauricular Skin Tag 0000369 Low-set Ears 000037 Abnormality of the Pinna _____ _____ |
CANCER ..... Type of Cancer _____ Age of Diagnosis _____ Family History of Cancer and Affected Relatives _____ |
GENES OF INTEREST ..... _____ _____ |
ADDITIONAL CLINICAL INFORMATION
DIFFERENTIAL DIAGNOSIS
Consent on next page
6 // 9
BAYLOGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name Carson Patient First Name Henry MI Date of Birth (MM / DD / YYYY) 01 / 01 / 1992 Genetic Sex M
WHOLE EXOME SEQUENCING (WES) AND WHOLE GENOME SEQUENCING (WGS) CONSENT
This consent form can only be used for whole exome sequencing and whole genome sequencing. Consent forms for other tests are located at Baylor Genetics' website (https://www.baylorgenetics.com/consent/).
For the purposes of this consent, "I", "my", "you", and "your" can refer to you, your child, your unborn child, or other individual you are the legal representative of.
TEST INFORMATION
Your healthcare provider (doctor, genetic counselor, or other person with medical training) wants to order a genetic test called Whole Genome Sequencing (WGS) or Whole Exome Sequencing (WES). These tests look for changes, called variants, in a person's DNA that can cause health issues. DNA is our genetic material. These variants can be in certain genes, specific parts of our DNA that are needed for our health. They can also be found in other places in the genome (all DNA that a person has). Based on your known health issues, variants in your DNA that may cause these issues will be reported. This test may explain your health issues. It may also explain health issues that your family may have. Even if this test finds the cause of your health issues, this may not help treat or manage those issues.
Testing where your DNA is compared to one or more family members may be performed. This may help better understand your results or show if your family members have the same variant as you.
Before you sign this consent form, you should speak with your healthcare provider. They can help you understand this testing and what it means for your health.
TEST RESULTS
There are several types of test results that may be reported including:
- Positive: A variant in the DNA was found that is related to your health issues or a health issue that you are at an increased risk of having in the future. These changes that cause disease are also known as pathogenic variants.
- Negative: No variants in the DNA were found that are related to your health issues or that would increase your risk of a health issue in the future.
- Variant of Uncertain Clinical Significance (VUS): A variant in the DNA was found that we do not know its effect, if any, on health. More testing may be needed for you or your family if a VUS is found that may be associated with your health issues.
- Secondary and Incidental Findings (Optional): Testing can sometimes find a variant in the DNA not related to the reason for testing but can change your medical care. Note: Certain issues within the brain start in adulthood and get worse over time (neurodegenerative). They often have no cure or treatment. By default, these variants will not be reported unless they are related to your health issues. However, variants in one or more of these gene(s) can be requested if needed. Your provider must write each gene needed in your test order.
- Genes of No Known Disease Association (Optional): Testing may find a variant in a gene that is not known to cause disease. This may be helpful to learn more about these genes in the future. These results do not currently impact medical management or indicate a diagnosis.
SECONDARY AND INCIDENTAL FINDINGS
The following categories of variants are not expected to cause your current health issues. However, they can each be requested to be reported. Knowing about these variants might affect your future medical care.
- ACMG Secondary Findings: The American College of Medical Genetics and Genomics (ACMG) recommends reporting disease-causing variants in certain genes that cause health issues. Each family member can request this group of variants to be reported.
- Incidental Findings: Other variants known to cause health issues but that are not causing your current health issues.
CONSIDERATIONS AND LIMITATIONS
- You should speak with your provider before signing this consent form to understand the risks, benefits, and alternatives to testing.
- Testing may show you have, or are at increased chance of having, a health issue. It may show that you have an increased chance of having a child with a health issue.
- Even if the variant(s) causing your health issues are found, how these issues might progress or improve with treatment might not be known. Affected family members with the same variant might not be affected like you are.
- Depending on the results of testing, more testing may be needed to understand these results. This testing might be needed for you and/or other family members.
- A negative result does not rule out the chance for health issues. Our knowledge of variants and how they cause disease may change over time as we learn more about genetics. Testing has limitations to what it can find as well.
- Certain factors may lead to incorrect results. These include mislabeled samples, incorrect information in the test order, and rare technical errors.
- More sample may be needed from you if the first sample is not sufficient to complete testing.
USE OF DATA AND SPECIMEN FOR RESEARCH PURPOSES
Biological specimens, test results, and associated information may be used by Baylor Genetics and its research partners for anonymous or coded research purposes, including improving genetic testing, advancing knowledge of genetic conditions, and developing new technologies, including inclusion in de-identified clinical databases, only with the patient's informed consent. Patient data and specimen will not be used for anonymous or coded research, unless authorized by marking below. A patient's decision to decline participation shall not affect their ability to receive testing from Baylor Genetics.
For Oregon patients, please consult the state specific consent form found at www.baylorgenetics.com/forms.
I authorize Baylor Genetics the use of my specimen and de-identified data for research.
FOR SAMPLES FROM NEW YORK STATE RESIDENTS
Samples from New York State residents shall not be included in research without written consent. Samples will not be retained for more than sixty (60) days after receipt by Baylor Genetics, unless authorized by marking below. No tests other than those authorized shall be performed on the samples.
I authorize Baylor Genetics to retain sample(s) longer based on our retention policy for test development, quality assurance, and training purposes.
7 // 9
BAYLORGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77201-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my" and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
[Handwritten Signature] [Handwritten Signature] MI [Handwritten Signature] Date of Birth (MM / DD / YYYY) [Handwritten Signature]
Patient Last Name Patient First Name Patient Last Name Date of Birth (MM / DD / YYYY) Genetic Sex Patient Last Name
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION
- • If several family members are tested, knowing the correct biological relationships among them is important. In rare cases, testing can show that family members are not related as expected. If this is found, we may contact the provider who ordered your testing.
- • If this testing is requested to be cancelled after the order and sample are sent to the laboratory, please see our Test Cancellation Policy at www.bayloregenetics.com/cancel-test/.
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION (CONTINUED)
- • Only Baylor Genetics and its contracted partners will have access to your sample for the ordered testing. Results from testing will only be released to: (i) a licensed healthcare provider, (ii) those authorized in writing, (iii) the patient or their personal representative, and (iv) those allowed access to test results by law. You have the right to access your test results from Baylor Genetics by providing a written request. You also have the right to request raw data obtained from your sample by providing a written request or HIPAA Authorization Form.
- • In rare cases, people with genetic diseases may have problems with health insurance and employment. The U.S. Federal Government has several laws that prohibit discrimination based on test results by health insurance companies and employers. These laws also prohibit unauthorized disclosure of this information. For more information, please visit www.genome.gov/10002077.
- • Samples will be kept in the laboratory based on our retention policy. Once testing is completed, the de-identified sample may be used for test development, quality assurance, and training purposes. Samples are not returned to patients or providers unless requested prior to testing. You and your heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
- • The information from your testing may be used in scientific research, publications or presentations, but your specific identity will not be revealed. We may contact your provider to obtain more clinical information about you. Baylor Genetics also performs other types of scientific research and may contact you to see if you would like to be involved.
- • Variants found may be submitted to databases. The medical community uses these databases to collect information about how variants might cause disease to improve testing and treatment for patients. An example is ClinVar, a free, public archive of reports on human genetics. Limited clinical information may need to be shared with these databases. In rare cases, this information may be enough to allow you or your family members to be identified.
- • For more information on privacy practices at Baylor Genetics, please visit www.bayloregenetics.com/privacy-practices/.
FINANCIAL AGREEMENT
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. I designate Baylor Genetics as my designated representative for purposes of appealing any denial of benefits by my insurance carrier. I irrevocably assign associated payment to Baylor Genetics, and direct that payment be made directly to Baylor Genetics. Please note, some payers may not cover certain screening tests.
If my health insurer does not cover the test or I do not have health insurance, I have received a good faith estimate of the cost for the genetic testing ordered by my provider and agree to pay for the cost of the genetic testing billed to me by Baylor Genetics based on that good faith estimate. More information is available in Baylor Genetics' No Surprises Act and Good Faith Estimate Notice located at https://www.bayloregenetics.com/no-surprises-act/.
A Medicare Advance Beneficiary Notice (ABN) is required for services Medicare identifies as not medically necessary.
PATIENT AUTHORIZATION
By signing this statement of consent, I acknowledge that I have read, understand, and hereby grant my informed consent for genetic testing. I have received appropriate explanations from my healthcare provider about the planned genetic test(s) and possible results. I have been informed by my healthcare provider about the availability and importance of genetic counseling and have been provided with written information identifying a genetic counselor or medical geneticist who can provide such counseling services. All my questions have been answered, and I have had the necessary time to make an informed decision about the genetic test(s).
Note: If Prenatal WES was ordered, please leave the Patient section blank and complete only a section for each relative tested below.
I hereby give permission to Baylor Genetics to conduct genetic testing as recommended by my healthcare provider.*
/ /
| Patient Name | Patient Signature | Date Signed (MM / DD / YYYY) |
| Relationship to Patient | Name | Signature |
| Relative 1 | Name | Signature |
| Relative 2 | Name | Signature |
| Relative 3 | Name | Signature |
If one or more family members have a Representative signing on their behalf:
/ /
| Name | Signature | Date (MM / DD / YYYY) | Representative For | Relationship to Represented Person(s) |
*If you are signing on behalf of the patient as the parent(s) and/or person with legal authority to act on behalf of the patient or parent, you may be required to provide evidence of your authority.
8 / 9
BAYLOWEGENETICS.COM
03.26.26
The logo for Baylor Genomics, featuring a black abstract geometric shape.
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2026
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE GENOME SEQUENCING (WGS)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Cash
_____
Patient Last Name
Terry
_____
Patient First Name
_____
MI
01/25/1995
_____
Date of Birth (MM / DD / YYYY)
fm
_____
Genetic Sex
FOR SURROGATES PREGNANCIES - FOR PRENATAL WGS ONLY:
Maternal cell contamination (MCC) studies use blood or another sample from a pregnant person. MCC studies are used to determine that the sample being tested belongs to the fetus and not the pregnant person. The results of MCC studies are not used for the treatment or management of the fetus, pregnant person, or other individuals, and are not part of the pregnant person's designated medical record.
I hereby give permission for my sample to be used for MCC studies:
_____
Surrogate Name
_____
Surrogate Signature
____/____/_____
Date Signed (MM / DD / YYYY)
9 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
A. Ordering Physician Name: _____
B. Patient Name: _____ C. Identification Number: _____
NOTE: If Medicare doesn't pay for a Baylor Genetics test below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for one or more of the Baylor Genetics test(s) below.
| D. Laboratory Tests | E. Reason Medicare May Not Pay: | F. Estimated Cost |
|---|---|---|
| Trio Whole Genome Sequencing | Medicare does not pay for this test for your condition. | $3,500 |
| Duo Whole Genome Sequencing | $3,500 | |
| Proband Whole Genome Sequencing | $3,000 | |
| Quad Whole Genome Sequencing | $6,200 | |
| Global Metabolomic Assisted Pathway Screen -- Plasma from EDTA | $1,000 | |
| Global Metabolomic Assisted Pathway Screen-U | $1,000 |
WHAT YOU NEED TO DO NOW:
- • Read this notice, so you can make an informed decision about your care.
- • Ask us any questions that you may have after you finish reading.
- • Choose an option below about whether to receive the Baylor Genetics test listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
| G. OPTIONS: Check only one box. We cannot choose a box for you. | |
|---|---|
| OPTION 1. I want the Baylor Genetics Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. | |
| OPTION 2. I want the Baylor Genetics Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. | |
| OPTION 3. I don't want the Baylor Genetics Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. | |
H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may ask to receive a copy.
| I. Signature: _____ | J. Date: _____ |
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp.01/31/2026) Confidential Property of Baylor Genetics Form Approved OMB No. 0938-0566
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
WHOLE EXOME SEQUENCING (WES) REQUISITION
06/05/1996
PATIENT INFORMATION (COMPLETE ONE FORM FOR EACH PERSON TESTED)
1 [initials] Patient Last Name
1246 Mississippi Road Address
Zip Patient First Name
Dawn City
[initials] MI Date of Birth (MM / DD / YYYY)
60 / 96 / 205-338
State Zip County
Gender: Male Female Unknown Other Identity (if different from above): BPM
ORDERING PHYSICIAN
[Signature] Ordering Physician
TTHS Institution Code
Santhis Hospital South Institution Name
Emergin NUI Email (Required for International Clients)
330-0685-3704 Phone
ADDITIONAL REPORTS
Cecil Mathew Smith Name
Cecil Mathewngualden Email
888-760-3224/432-804-428 Phone
888-668-7750 Fax
Note: Reports will be sent by FAX except for international recipients
PAYMENT (FILL OUT ONE OF THE OPTIONS BELOW)
- SELF PAYMENT .....
- Pay With Sample Bill To Patient
- INSTITUTIONAL BILLING .....
| Institution Name | Institution Code | Institution Contact Name | Institution Phone | Institution Contact Email |
INSURANCE .....
Do not perform test until patient is aware of out-of-pocket costs (excludes prenatal testing)
REQUIRED ITEMS
|
1. Copy of the Front/Back of Insurance Card(s) 3. Name of Ordering Physician Commercial Medicaid Medicare* |
2. ICD10 Diagnosis Code(s) 4. Insured Signature of Authorization ICD10 Diagnosis Code(s) (Required): |
*A completed Advance Beneficiary Notice (ABN) is required for Medicare patients that do not meet Medicare criteria.
Has the patient been a hospital inpatient in the last 14 days?
- No, the patient was not an inpatient Yes, the patient was an inpatient (hospital stay longer than 24 hours)
| Blue Cross | 883-674-4450 | ||
| Primary Insurance Co. Name | Primary Insurance Co. Phone | Secondary Insurance Co. Name | Secondary Insurance Co. Phone |
| 88-66-772216 | 11-24-3666 | ||
| VMDA & P | 01/01/2000 | ||
| Primary Member Policy # | Primary Member Group # | Secondary Member Policy # | Secondary Member Group # |
| DASHAR | 15-567-210 | / / | |
| Name of Insured | Insured Date of Birth (MM / DD / YYYY) | Name of Insured | Insured Date of Birth (MM / DD / YYYY) |
| DASHAR | |||
| Patient's Relationship to Insured | Phone of Insured | Patient's Relationship to Insured | Phone of Insured |
| 11440 Caterine Line | |||
| Address of Insured | Address of Insured | ||
| Kansas City | KS 46721 | ||
| City | State | State | Zip |
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. If self-pay is selected, I agree to pay for the cost of testing ordered and billed by Baylor Genetics as outlined in the Good Faith Estimate I received. I understand that I am responsible for sending Baylor Genetics any and all payments that I receive directly from my insurance company in payment for this test. Please note, Medicare may not cover certain screening tests.
[Signature] Patient / Guardian Printed Name [Signature] Patient / Guardian Signature Date (MM / DD / YYYY) 01/01/2020
1 // 9 BAYLRGENETICS.COM 03.24.24
GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
1.800.411.4363
FAX
1.800.434.9850
IN X G f y
This requisition hereby incorporates the Terms and Conditions of the Laboratory Services found at https://www.baylorgenetics.com/lab-terms-conditions/ or, in the case of international entities, https://www.baylorgenetics.com/terms-conditions-of-the-laboratory-services-international/. This test is medically necessary for the risk assessment, diagnosis, or detection of a disease, illness, impairment, symptom, syndrome, or disorder. The results will determine my patient's medical management and treatment decisions. The person listed as the Ordering Physician is authorized by law to order the test(s) requested herein. I confirm that I have provided genetic testing information to the patient, and they have consented to genetic testing.
Familial samples are required for non-Proband WES. Please contact the laboratory if placing a test order where the comparator(s) are different than the required family members listed.
For select cases as determined by Baylor Genetics, WES may be supplemented by RNA-Seq to aid with variant classification as a standard part of this test offering. If the originally submitted specimen is blood and meets all established specimen requirements, RNA-Seq will be reflexively performed without additional authorization. If these requirements are not met, submission of a new blood specimen may be requested, or reflexive testing may not be performed. A final report will be issued prior to initiating RNA-Seq. Any updates resulting from this additional technology will be provided through a addened report.
1600 Trio Whole Exome Sequencing
1722 Rapid Trio Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS
(Both Biological Parents Are Required)
1550 Comparator WES
Maternal Paternal
1602 WES - Additional Affected Sibling
1603 Duo Whole Exome Sequencing
1723 Rapid Duo Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS
(One Biological Parent Is Required)
1550 Comparator WES
Maternal Paternal
1602 WES - Additional Affected Sibling
1500 Proband Whole Exome Sequencing
1729 Rapid Proband Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS
6997 Parental Control
Maternal Paternal
1604 Quad Whole Exome Sequencing
1724 Rapid Quad Whole Exome Sequencing
CORRESPONDING COMPARATOR TESTS
(Both Biological Parents + One Additional Family Member Are Required)
1550 Comparator WES
Maternal Paternal
1550 Comparator WES
Sibling Child
Maternal: Half-Sibling Aunt/Uncle
Grandparent First Cousin
Paternal: Half-Sibling Aunt/Uncle
Grandparent First Cousin
4900 Global Metabolomic Assisted Pathway Screen - Plasma from EDTA
Was plasma extracted from EDTA? Yes No
4901 Global Metabolomic Assisted Pathway Screen - Urine
8665 Chromosomal Microarray Analysis (CMA)-HR+SNP Screen (Comprehensive)
2055 Comprehensive mtDNA analysis by NGS
9815 Exome Raw Data Release
Note: Any combination of Chromosomal Microarray Analysis (CMA), mtDNA Analysis, or Global MAPS* can be ordered along with a WES test, however the turnaround time for results will differ from exome sequencing.
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE 1.800.411.4363
FAX 1.800.434.9850
CONNECT
Patient First Name _____ Patient ID _____ MI AO Date of Birth (MM / DD / YYYY) 02/07/1976 Genetic Sex
(Handwritten signatures over Patient First Name and Medical Identifier)
If a box is not checked the tab will default to No / Not Report.
Option for Reporting of ACMG Secondary Findings
Variants in genes included in the ACMG secondary findings guidelines will be reported for each family member marked below. Each marked family member will receive their own report on these findings.
Proband Mother Father Other Family Member
Option for Reporting of Incidental Findings
Pathogenic and likely pathogenic variants in genes covered under Category II of the Incidental Findings section of the consent form will be reported.
Please report pathogenic and likely pathogenic variants in genes associated with Incidental Findings.
Trio and Quad Orders with Both Parents Only – Option for Reporting of Research Findings
For variants in genes with no known disease association, these variants will be reported if biallelic or de novo.
Please report biallelic and de novo variants in genes with no known disease association.
Please refer to www.baylorgenetics.com for full sample requirements.
| Blood in EDTA (preferred) |
| Buccal Swab |
| Cord Blood |
| Cultured Skin Fibroblast |
mtDNA analysis only
| Skeletal Muscle |
| Liver |
| Tissue |
Global MAPS® only
| Plasma from EDTA | Urine |
Date of Collection (MM / DD / YYYY)
NOTE: Extracted DNA/RNA will only be accepted if the isolation of nucleic acids for clinical testing occurs in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS.
| Comparator | Last Name | First Name | Genetic Sex | Date of Birth (MM / DD / YYYY) | Date of Collection (MM / DD / YYYY) | Sample Type | Symptomatic? (Attach summary of findings if Yes) |
|---|---|---|---|---|---|---|---|
| Maternal _____ | Boyer | Erica | [Hatched Box] | 01/08/2004 | / / / | Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
| Paternal _____ | Boyer | Erin | [Hatched Box] | 02/08/2022 | / / / | Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
| Other Family Member: | Female Male |
||||||
| Maternal: Sibling Child Half-Sibling Aunt/Uncle Grandparent First Cousin |
/ / / | / / / | Blood in EDTA (preferred) Buccal Swab Saliva |
Yes No |
|||
| Paternal: Half-Sibling Aunt/Uncle Grandparent First Cousin |
Proband Sample (Required) Clinical Note/Summary Pedigree (Optional)
Comparator Samples Requisition Signed WES Consent Form Indication for Study
* This sample type incurs an additional fee and typically adds 14 days to the turnaround time, depending on sample quality.
† Baylor Genetics will store this sample for up to 14 days after the report is issued, allowing for follow-up testing if needed.
3 // 9
BAYLORGENETICS.COM
03.26.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
Handwritten initials: M, dtd 1/13/24, um
Patient Last Name: [handwritten]
Patient First Name: [handwritten] MI [handwritten]/ [handwritten] [handwritten]
Date of Birth (MM / DD / YYYY): [handwritten] / [handwritten] / [handwritten]
Genetic Sex:
INDICATION FOR TESTING (REQUIRED)
Please provide the following clinical information regarding the patient to be tested. Please also submit a clinic note and pedigree, if available. Phenotypes listed are in HPO terms with the corresponding HPO number (http://human-phenotype-ontology.github.io/). This information is needed to facilitate interpretation of whole exome sequencing results. If the laboratory requires additional information, please indicate the health care provider to be contacted:
| PRE/PERINATAL HISTORY ..... | EYE DEFECTS & VISION ..... | MOTOR/COGNITIVE DEVELOPMENT ..... | |||
|---|---|---|---|---|---|
| 0001622 | Prematurity - GA at birth | 0000505 | Visual Impairment | 0000750 | Delayed Speech & Language Development |
| 0001511 | Intrauterine Growth Restrictions | 0000618 | Blindness | 0001270 | Delayed Motor Milestones |
| 0001562 | Oligohydramnios | 0000589 | Coloboma | 0002376 | Developmental Regression |
| [X] 0001561 | Polyhydramnios | 0000526 | Aniridia | Intellectual Disability |
|
| 0000476 | Cystic Hygroma | 0000528 | Anophthalmia | 0001256 | Mild |
| 0000776 | Congenital Diaphragmatic Hernia | 0000568 | Microphthalmia | 0002342 | Moderate |
| 0001508 | Failure to Thrive | 0000508 | Piosis | 0010864 | Severe |
| 0001539 | Omphalocele | 0000486 | Strabismus | 0000729 |
Autistic Spectrum Disorder |
| 0002084 | Encephalocele | X 0000519 | _____ _____ |
||
| 0010880 | _____ _____ |
||||
| STRUCTURAL BRAIN ABNORMALITIES ..... | NEUROLOGICAL ..... | CRANIOFACIAL ..... | |
|---|---|---|---|
| 0001360 | Holoprosencephaly | 0000256 | Macrocephaly |
| 0001339 | Lissencephaly | X 0000252 | Microcephaly |
| 0002084 | Encephalocele | 0001363 | Craniosynostosis |
| 0000238 | Hydrocephalus | 0000204 | Cleft Upper Lip |
| 0002119 | Ventriculomegaly | 0000175 | Cleft Palate |
| 0001273 | Abnormality of Corpus Callosum | 0000316 | Hypertelorism |
| 0002539 | Cortical Dysplasia | 0000601 | Hypotelorism |
| 0012444 | Brain Atrophy | 0008050 | Abnormality of the Palpebral Fissures |
| 0002352 | Leukoencephalopathy | 0000286 | Epicanthial Folds |
| 0002269 | Abnormality of Neuronal Migration | 0000288 | Abnormality of the Philtrum |
| 0002126 | Polymicrogyria | 0010938 | Abnormality of the External Nose |
| 0001302 | Pachgyria | ||
| 0002500 | Abnormality of Cerebral White Matter | X . | |
| 0007266 | Cerebral Dysmyelination | [Handwritten: lower lip cleft] | |
| 0008808 | Cerebral Hypomyelination | _____ _____ |
|
| 0002134 | Abnormality of the Basal Ganglia | ||
| 0002363 | Abnormality of the Brainstem | ||
| 0007360 | Aplasia/Hypoplasia of the Cerebellum | ||
| 0008817 | Aplasia/Hypoplasia of the Cerebellar Vermis | ||
Indications continued on next page
4 / 9 BAYLORGENETICS.COM 03.23.26
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
WHOLE EXOME SEQUENCING (WES) REQUISITION
Paprz
_____
Patient Last Name
dip
_____
Patient First Name
MI
06/06/1976
_____
Genetic Sex
INDICATION FOR TESTING (REQUIRED) - CONTINUED
HAIR & SKIN
0000957 Cafe-Au-Lait Spots
0001034 Hypermelanotic Macule
0001010 Hypopigmentation of the Skin
0008066 Abnormal Blistering of the Skin
0008064 Ichthyosis
0000988 Skin Rash
0001581 Recurrent Skin Infections
0005306 Capillary Hemangiomas
0001597 Abnormality of the Nail
0004554 Generalized Hypertrichosis
✓ 0001596 Alopecia
0002208 Coarse Hair
0002299 Brittle Hair
_____
_____
CARDIAC
0001631 Atria Septal Defect
0001629 Ventricular Septal Defect
0001655 Patent Foramen Ovale
0001713 Abnormality of Cardiac Ventricles
0001636 Tetralogy of Fallot
0001680 Coarctation of Aorta
0001647 Bicuspid Aortic Valve
0002616 Aortic Root Dilatation
✓ 0001638 Cardiomyopathy
0011675 Arrhythmia
_____
_____
GENITOURINARY
0000113 Polycystic Kidney Dysplasia
0000107 Renal Cyst
0008738 Partially Duplicated Kidney
0000104 Renal Agenesis
0000085 Horseshoe Kidney
0000069 Abnormality of the Ureter
0000795 Abnormality of the Urethra
0000047 Hypospadias
0000028 Cryptorchidism
0000035 Abnormality of the Testis
✓ 0000062 Ambiguous Genitalia
_____
_____
RESPIRATORY
0002093 Respiratory Insufficiency
0002878 Respiratory Failure
0002104 Apnea
0002791 Hypoventilation
0002883 Hyperventilation
0002788 Recurrent Upper Respiratory Tract Infections
_____
_____
METABOLIC
0001946 Ketosis
0003074 Hyperglycemia
0001943 Hypoglycemia
0001941 Acidosis
0003128 Lactic Acidosis
0003215 Dicarboxylic Aciduria
0002490 Increased CSF lactate
0001992 Organic Aciduria
0030085 Abnormal CSF Lactate Level
00003542 Increased Serum Pyruvate
0003535 3-Methylglutaconic aciduria
0001942 Metabolic acidosis
0100493 Hypoammonemia
0001987 Hyperammonemia
0004923 Hyperphenylalaninemia
✓ 0003234 Decreased Plasma Carnitine
0003236 Elevated Serum Creatine Phosphokinase
Abnormal Newborn Screen
♂ Unusual Color/Odor
_____
_____
MUSCULOSKELETAL
0011398 Hypotonia
0001276 Hypertonia
0000098 Tall Stature
0004322 Short Stature
✳ 0001382 Joint Hypermobility
0001371 Flexion Contracture
0002804 Arthrogryposis Multiplex Congenita
0001161 Hand Polydactyly
0001829 Foot Polydactyly
0006101 Finger Syndactyly
0001770 Toe Syndactyly
0100490 Camptodactyly of Finger
0012165 Oligodactyly
0001762 Talipes Equinovarus
0002757 Recurrent Fractures
♂ 0002650 Scoliosis
0002808 Kyphosis
0003307 Hyperlordosis
♂ 0001528 Hemihypertrophy
0001513 Obesity
0001548 Overgrowth
0002652 Skeletal Dysplasia
_____
_____
GASTROINTESTINAL
✳ 0002021 Pyloric Stenosis
0002575 Tracheoesophageal Fistula
0002032 Esophageal Atresia
0002020 Gastroesophageal Reflux
0001733 Pancreatitis
0002014 Diarrhea
0002019 Constipation
0002037 Inflammatory Bowel Disease
0004389 Intestinal Pseudo-Obstruction
0001399 Hepatic Failure
0002572 Episodic Vomiting
0001744 Splenomegaly
0002240 Hepatomegaly
0001508 Postnatal Failure to Thrive
0002578 Gastroparesis
_____
_____
Indications continued on next page
5 // 9
BAYLORGENETICS.COM
03.24.24
GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
1.800.411.4363
FAX
1.800.434.9850
- 0000819 Diabetes Mellitus
- 0000873 Diabetes Insiplus
- 0000821 Hypothyroidism
- 0000829 Hypoparathyroidism
- 0000834 Abnormality of the Adrenal Glands
- 0001738 Exocrine Pancreatic Insufficiency
- 0002721 Immunodeficiency
- 0000407 Sensorineural Hearing Impairment
- 00008619 Bilateral
- 0000405 Conductive Hearing Impairment
- 0000410 Mixed Hearing Impairment
- 0004467 Preauricular Pit
- 0000384 Preauricular Skin Tag
- 0000369 Low-set Ears
- 000037 Abnormality of the Pinna
- 0001875 Neutropenia
- 0005549 Congenital
- Chronic
- Cyclic
- 0001873 Thrombocytopenia
- 0040185 Macrothrombocytopenia
- 0005537 Decreased Mean Platelet Volume
- 0005518 Erythrocyte Macrocytosis
- 0004444 Spherocytosis
- 0012410 Pure Red Cell Aplasia
- Aplastic
- Hypoplastic
- 0001903 Anemia
- 0005528 Bone Marrow Hypocellularity
- Type of Cancer _____
- Age of Diagnosis _____
- Family History of Cancer and Affected Relatives
- Organomegaly
- Chronic Infections
- 0004311 Abnormality of Macrophages
- 0001954 Episodic Fever
- 0004313 Hypogammaglobulinemia
- 0010701 Abnormal Immunoglobulins
- 0002721 Immunodeficiency
- 0012088 Abnormal urinary odor
- 0012537 Food intolerance
- 0008067 Abnormally lax or hyperextensible skin
- Abnormal Movements
- Family History of Similar Disorder
- 0001254 Lethargy
- 0002415 Leukodystrophy
_____
_____
_____
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE EXOME SEQUENCING (WES)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name: [Handwritten: TACCO] Patient First Name: [Handwritten: FREDERICK] MI: _____ Date of Birth (MM / DD / YYYY): [Handwritten: 03/13/2024] Genetic Sex: [Handwritten: U]
WHOLE EXOME SEQUENCING (WES) AND WHOLE GENOME SEQUENCING (WGS) CONSENT
This consent form can only be used for whole exome sequencing and whole genome sequencing. Consent forms for other tests are located at Baylor Genetics' website (https://www.baylorgenetics.com/consent/).
For the purposes of this consent, "I", "my", "you", and "your" can refer to you, your child, your unborn child, or other individual you are the legal representative of.
TEST INFORMATION
Your healthcare provider (doctor, genetic counselor, or other person with medical training) wants to order a genetic test called Whole Genome Sequencing (WGS) or Whole Exome Sequencing (WES). These tests look for changes, called variants, in a person's DNA that can cause health issues. DNA is our genetic material. These variants can be in certain genes, specific parts of our DNA that are needed for our health. They can also be found in other places in the genome (all DNA that a person has). Based on your known health issues, variants in your DNA that may cause these issues will be reported. This test may explain your health issues. It may also explain health issues that your family may have. Even if this test finds the cause of your health issues, this may not help treat or manage those issues.
Testing where your DNA is compared to one or more family members may be performed. This may help better understand your results or show if your family members have the same variant as you.
Before you sign this consent form, you should speak with your healthcare provider. They can help you understand this testing and what it means for your health.
TEST RESULTS
There are several types of test results that may be reported including:
- Positive: A variant in the DNA was found that is related to your health issues or a health issue that you are at an increased risk of having in the future. These changes that cause disease are also known as pathogenic variants.
- Negative: No variants in the DNA were found that are related to your health issues or that would increase your risk of a health issue in the future.
- Variant of Uncertain Clinical Significance (VUS): A variant in the DNA was found that we do not know its effect, if any, on health. More testing may be needed for you or your family if a VUS is found that may be associated with your health issues.
- Secondary and Incidental Findings (Optional): Testing can sometimes find a variant in the DNA not related to the reason for testing but can change your medical care. Note: Certain issues within the brain start in adulthood and get worse over time (neurodegenerative). They often have no cure or treatment. By default, these variants will not be reported unless they are related to your health issues. However, variants in one or more of these gene(s) can be requested if needed. Your provider must write each gene needed in your test order.
- Genes of No Known Disease Association (Optional): Testing may find a variant in a gene that is not known to cause disease. This may be helpful to learn more about these genes in the future. These results do not currently impact medical management or indicate a diagnosis.
SECONDARY AND INCIDENTAL FINDINGS
The following categories of variants are not expected to cause your current health issues. However, they can each be requested to be reported. Knowing about these variants might affect your future medical care.
- ACMG Secondary Findings: The American College of Medical Genetics and Genomics (ACMG) recommends reporting disease-causing variants in certain genes that cause health issues. Each family member can request this group of variants to be reported.
- Incidental Findings: Other variants known to cause health issues but that are not causing your current health issues.
CONSIDERATIONS AND LIMITATIONS
- You should speak with your provider before signing this consent form to understand the risks, benefits, and alternatives to testing.
- Testing may show you have, or are at increased chance of having, a health issue. It may show that you have an increased chance of having a child with a health issue.
- Even if the variant(s) causing your health issues are found, how these issues might progress or improve with treatment might not be known. Affected family members with the same variant might not be affected like you are.
- Depending on the results of testing, more testing may be needed to understand these results. This testing might be needed for you and/or other family members.
- A negative result does not rule out the chance for health issues. Our knowledge of variants and how they cause disease may change over time as we learn more about genetics. Testing has limitations to what it can find as well.
- Certain factors may lead to incorrect results. These include mislabeled samples, incorrect information in the test order, and rare technical errors.
- More sample may be needed from you if the first sample is not sufficient to complete testing.
USE OF DATA AND SPECIMEN FOR RESEARCH PURPOSES
Biological specimens, test results, and associated information may be used by Baylor Genetics and its research partners for anonymous or coded research purposes, including improving genetic testing, advancing knowledge of genetic conditions, and developing new technologies, including inclusion in de-identified clinical databases, only with the patient's informed consent. Patient data and specimen will not be used for anonymous or coded research, unless authorized by marking below. A patient's decision to decline participation shall not affect their ability to receive testing from Baylor Genetics.
For Oregon patients, please consult the state specific consent form found at www.baylorgenetics.com/forms.
I authoriz e Baylor Genetics the use of my specimen and de-identified data for research.
FOR SAMPLES FROM NEW YORK STATE RESIDENTS
Samples from New York State residents shall not be included in research without written consent. Samples will not be retained for more than sixty (60) days after receipt by Baylor Genetics, unless authorized by marking below. No tests other than those authorized shall be performed on the samples.
I authorize Baylor Genetics to retain sample(s) longer based on our retention policy for test development, quality assurance, and training purposes.
7 // 9
BAYLorgenetics.COM
03.24.24
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
INFORMED CONSENT FOR WHOLE EXOME SEQUENCING (WES)
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
Patient Last Name: PADZ Patient First Name: RIP MI: _____ Date of Birth (MM / DD / YYYY): 06 / 06 / 1991 Genetic Sex: U
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION
- If several family members are tested, knowing the correct biological relationships among them is important. In rare cases, testing can show that family members are not related as expected. If this is found, we may contact the provider who ordered your testing.
- If this testing is requested to be cancelled after the order and sample are sent to the laboratory, please see our Test Cancellation Policy at www.baylorgenomics.com/cancel-test/.
PATIENT CONFIDENTIALITY AND SAMPLE RETENTION (CONTINUED)
- Only Baylor Genetics and its contracted partners will have access to your sample for the ordered testing. Results from testing will only be released to: (i) a licensed healthcare provider, (ii) those authorized in writing, (iii) the patient or their personal representative, and (iv) those allowed access to test results by law. You have the right to access your test results from Baylor Genetics by providing a written request. You also have the right to request raw data obtained from your sample by providing a written request or HIPAA Authorization Form.
- In rare cases, people with genetic diseases may have problems with health insurance and employment. The U.S. Federal Government has several laws that prohibit discrimination based on test results by health insurance companies and employers. These laws also prohibit unauthorized disclosure of this information. For more information, please visit www.genome.gov/10000277.
- Samples will be kept in the laboratory based on our retention policy. Once testing is completed, the de-identified sample may be used for test development, quality assurance, and training purposes. Samples are not returned to patients or providers unless requested prior to testing. You and your heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
- The information from your testing may be used in scientific research, publications or presentations, but your specific identity will not be revealed. We may contact your provider to obtain more clinical information about you. Baylor Genetics also performs other types of scientific research and may contact you to see if you would like to be involved.
- Variants found may be submitted to databases. The medical community uses these databases to collect information about how variants might cause disease to improve testing and treatment for patients. An example is ClinVar, a free, public archive of reports on human genetics. Limited clinical information may need to be shared with these databases. In rare cases, this information may be enough to allow you or your family members to be identified.
- For more information on privacy practices at Baylor Genetics, please visit www.baylorgenomics.com/privacy-practices/.
FINANCIAL AGREEMENT
By signing below, I hereby authorize Baylor Genetics to provide my insurance carrier any information necessary, including test results, for processing my insurance claim. I understand that I am responsible for any co-pay, co-insurance, and unmet deductible that the insurance policy dictates. I designate Baylor Genetics as my designated representative for purposes of appealing any denial of benefits by my insurance carrier. I irrevocably assign associated payment to Baylor Genetics, and direct that payment be made directly to Baylor Genetics. Please note, some payers may not cover certain screening tests.
If my health insurer does not cover the test or I do not have health insurance, I have received a good faith estimate of the cost for the genetic testing ordered by my provider and agree to pay for the cost of the genetic testing billed to me by Baylor Genetics based on that good faith estimate. More information is available in Baylor Genetics' No Surprises Act and Good Faith Estimate Notice located at https://www.baylorgenomics.com/no-surprises-act/.
A Medicare Advance Beneficiary Notice (ABN) is required for services Medicare identifies as not medically necessary.
PATIENT AUTHORIZATION
By signing this statement of consent, I acknowledge that I have read, understand, and hereby grant my informed consent for genetic testing. I have received appropriate explanations from my healthcare provider about the planned genetic test(s) and possible results. I have been informed by my healthcare provider about the availability and importance of genetic counseling and have been provided with written information identifying a genetic counselor or medical geneticist who can provide such counseling services. All my questions have been answered, and I have had the necessary time to make an informed decision about the genetic test(s).
Note: If Prenatal WES was ordered, please leave the Patient section blank and complete only a section for each relative tested below.
I hereby give permission to Baylor Genetics to conduct genetic testing as recommended by my healthcare provider.*
MMHMM
Patient Name
[Signature]
Patient Signature
/ /
Date Signed (MM / DD / YYYY)
| Relationship to Patient | Name | Signature | Date |
|---|---|---|---|
| Relative 1 | |||
| Relative 2 | |||
| Relative 3 | |||
| If one or more family members have a Representative signing on their behalf: | |||
| Name | Signature | Date (MM / DD / YYYY) | Representative For Relationship to Represented Person(s) |
*If you are signing on behalf of the patient as the parent(s) and/or person with legal authority to act on behalf of the patient or parent, you may be required to provide evidence of your authority.
8 / / 9
03.26.24
BAYLOR
GENETICS
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE
1.800.411.4363
FAX
1.800.434.9850
CONNECT
For the purposes of this consent, "you", "me", "my", and "I" can also mean your child (including unborn child) or the individual you are the personal representative for.
_____
Patient Last Name
_____
Patient First Name
_____
MI
_____/_____/_____
Date of Birth (MM / DD / YYYY)
_____
Genetic Sex
FOR SURROGATES PREGNANCIES - FOR PRENATAL WES ONLY:
Maternal cell contamination (MCC) studies use blood or another sample from a pregnant person. MCC studies are used to determine that the sample being tested belongs to the fetus and not the pregnant person. The results of MCC studies are not used for the treatment or management of the fetus, pregnant person, or other individuals, and are not part of the pregnant person's designated medical record.
I hereby give permission for my sample to be used for MCC studies:
_____
Surrogate Name
_____
Surrogate Signature
_____/_____/_____
Date Signed (MM / DD / YYYY)
9 // 9
BAYLORGENETICS.COM
03.26.26
BAYLOR GENETICS
2450 HOLCOMBE BLVD.
SUITE 2210
HOUSTON, TX 77021-2024
PHONE 1.800.411.4363
FAX 1.800.434.9850
A. Ordering Physician Name: Dr. Marco Lopez
B. Patient Name: Phillp
C. Identification Number: _____
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn't pay for a Baylor Genetics test below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for one or more of the Baylor Genetics test(s) below.
| D. Laboratory Tests | E. Reason Medicare May Not Pay: | F. Estimated Cost |
|---|---|---|
| Duo Whole Exome Sequencing | Medicare does not pay for this test for your condition. | $2,400 |
| Trio Whole Exome Sequencing | $2,400 | |
| Quad Whole Exome Sequencing | $2,400 | |
| Proband WES | $1,800 | |
| Global Metabolomic Assisted Pathway Screen – Plasma from EDTA | $1,000 | |
| Global Metabolomic Assisted Pathway Screen – Urine | $1,000 |
WHAT YOU NEED TO DO NOW:
- • Read this notice, so you can make an informed decision about your care.
- • Ask us any questions that you may have after you finish reading.
- • Choose an option below about whether to receive the Baylor Genetics test listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
G. OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the Baylor Genetics Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the Baylor Genetics Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
OPTION 3. I don't want the Baylor Genetics Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:
Form CMS-R-131 (Exp.01/31/2026)
Confidential Property of Baylor Genetics
Form Approved OMB No. 0938-0566
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may ask to receive a copy.
| I. Signature: | J. Date: xx |
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
| Form CMS-R-131 (Exp.01/31/2026) | Confidential Property of Baylor Genetics | Form Approved OMB No. 0938-0566 |