I have been informed of and understand the details of the test ordered herein for me by my health care provider, including the risks, benefits, and alternatives, and have consented to testing.
I understand that the test results may inform me of a medical condition that may require medical follow-up.
I also understand that a negative result does not rule out the possibility of such medical condition.
I authorize Natera or other provider to share the information on this form and my test results with my insurer/health plan (“plan”) on my behalf, with all benefits of my plan made payable directly to Natera or other provider.
I understand that I am responsible for (a) costs not paid by my plan directly to Natera for tests ordered, including, without limitation, any copayments, deductibles, or amounts deemed ‘patient responsibility’ and (b) any amounts paid to me by my plan.
This testing will not be covered by my plan if it is outside of the plan’s coverage guidelines or deemed not medically necessary – (e.g. where prior authorization is required but not obtained) and I will be responsible for the cost of such testing (this does not apply to Medicare beneficiaries as a separate ABN is required).
I assign to Natera the right to appeal on my behalf negative coverage decisions made by my plan and to assert all rights and claims reserved to me as the beneficiary thereof. The information obtained from my tests may be used in scientific research, publications or presentations,but my specific identity will not be
revealed.
Natera may contact my healthcare provider to obtain more information regarding clinical correlation and confirmatory testing.
My leftover samples may be de-identified and used for research and development. I and my heirs will not receive payments, benefits, or rights to any resulting products or discoveries.
If I do not want my samples used for research and development purposes, I will send a request in writing to Natera Sample Retention Department at the address below within 60 days after test results have been issued and my samples will be destroyed
Last Update: Nina O ( May 27,2025)