Cal. Code Regs. tit. 10 § 2218.20
To determine whether or not to issue a life and/or a disability income insurance policy to you, and for purposes specified below, if any, which are related to a determination whether or not to issue a life and/or a disability income policy to you, we, [Insert full name of insurer.], require you to undergo testing of your genetic characteristics. Accordingly, we request your authorization to test you for the following scientifically or medically identifiable gene(s) or chromosome(s), or alteration(s) thereof, which is/are known to be a cause of, or which is/are determined to be associated with a statistically increased risk of development of the following disease(s) or disorder(s):
Gene/Chromosome: [Indicate gene(s) or chromosome(s).]
Disease/Disorder: [Indicate disease(s) or disorder(s).]
We will not obtain a test of any other genetic characteristics unless, in accordance with applicable law, we obtain an additional, separate written consent from you to do so. We will only test genes or chromosomes, or alterations thereof, which are presently associated with symptoms of the disease(s) or disorder(s) indicated above. We will, however, test the gene(s) or chromosome(s), or alteration(s) thereof, indicated above, which are presently associated with symptoms of the disease(s) or disorder(s) indicated above, whether or not you presently have symptoms of the disease(s) or disorder(s) with respect to which the test(s) will be conducted. We will pay the full cost for administering the test(s) of the gene(s) and/or chromosome(s) indicated above, interpreting the results of the test(s) specified above to the extent we consider necessary to make our determination whether or not to issue a life and/or disability income policy to you, and informing you about the results and interpretation of the test(s).
The following test(s) will be performed on you: [Identify each test by name and scientific reference identifier, if any.]
[Here, indicate what will be tested, and by whom, and, in plain language, the test methodology. For example, "The X laboratory will take a sample of your blood and examine it microscopically." Also provide the address and telephone number of the tester.]
Our primary purpose of the test(s) authorized by you is to obtain information about: [State the genetic characteristic(s) which will be indicated by the test or tests listed above.], in order to determine whether or not to issue a life and/or disability income insurance policy to you.
Other uses of the test(s) authorized, which are related to making a determination whether or not to issue a life and/or disability income insurance policy to you, include: [Indicate all uses which you will make of the test results, including but not limited to a decision about underwriting, and the effect of the results of the test(s) on premiums.] We will not use the tests for any other purposes.
Limitations of the test(s) include: [For each test authorized, indicate the limitations of the test, including, but not limited to, the relative degree of accuracy of each.]
We will notify you promptly and in writing about the results of the test(s) of your genetic characteristics. Our written notice to you of those results will provide you with the interpretation of the results of the test(s) of your genetic characteristics which we obtain with respect to making a determination whether or not to issue a life and/or disability income insurance policy to you. We recommend that you give us the name and address in the space below of a physician who can explain the test results and the interpretation of those results which we obtain more fully to you. If you give us the name and address of such a person, we will send the test results and the interpretation of those results which we obtain to that person and notify you in writing that we have done so. If you do not give us the name of a physician, we will send the test results and the interpretation of those results which we obtain directly to you.
We will treat the fact that you were asked to be tested, and whether or not you agreed to be tested, and the results and interpretation of the results of your test(s) which we obtain confidentially. Only persons within our company or under contract with our company who have a need to know about the testing and the test results for our underwriting purposes, and persons necessarily involved in administering the test and interpreting the test results for us, will have access to information about our request to test your genetic characteristics, whether or not you agreed to be tested for genetic characteristics for us, or the results and interpretation of the results of the test(s) of your genetic characteristics which we obtain. We will not disclose, nor allow anyone under contract with us or in our employ to disclose, information about our request to test your genetic characteristics, whether or not you agreed to be tested for genetic characteristics for us, or the results and interpretation of the results of the test(s) of your genetic characteristics which we obtain to anyone else unless you first authorize us in writing to do so, or we are compelled by law to do so.
Your signature below indicates that you have read and you understand this Notice and Consent to Test Genetic Characteristics and Confidentiality Agreement, and the obligations imposed on us by this document, and you voluntarily agree to submit to the test(s) indicated above. Your signature also indicates that you have received a copy of this document, and that a photocopy of this document which reflects your signature may be used by us to obtain testing of your genetic characteristics, as indicated above.
This authorization to test your genetic characteristics expires ninety (90) days from the date you sign it; however, you may revoke it at any time. Our obligations set forth in this Notice and Consent to Test Genetic Characteristics and Confidentiality Agreement, including but not limited to our obligations regarding confidentiality, do not expire, nor may we revoke or amend them without your prior written consent.
| ___________________________ | ___________________________ | |
| Signature of Proposed Insured | Date | |
| ___________________________ | ||
| Signature of Parent or Guardian | ||
| (When required by law) |
Physician to Whom Test Results May Be Sent:
Name: ____________________ Address: ____________________ Telephone:____________________
Cal. Code Regs. Tit. 10, § 2218.20
Note: Authority cited: Article 2.6 of Chapter 1 of Part 2 of Division 2 and Section 10148, California Insurance Code. Reference: Article 2.6 of Chapter 1 of Part 2 of Division 2 and Sections 10146- 10149.1, California Insurance Code.