Common use of HEALTH CARE PROVIDER INFORMATION AND SIGNATURE Clause in Contracts

HEALTH CARE PROVIDER INFORMATION AND SIGNATURE. Attending Physician's Signature Date Printed Name and Address of Health Care Provider: The Genetic Information Nondiscrimination Act of 2008 (XXXX) prohibits employers and other entities covered by XXXX Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by XXXX, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

HEALTH CARE PROVIDER INFORMATION AND SIGNATURE. Attending Physician's Signature Date Printed Name and Address of Health Care Provider: The Genetic Information Nondiscrimination Act of 2008 (XXXX) prohibits employers and other entities covered by XXXX Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by XXXX, includes an individual’s individual‟s family medical history, the results of an individual’s individual‟s or family member’s member‟s genetic tests, the fact that an individual or an individual’s individual‟s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s individual‟s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.