Newtopia Authorization for Release of Genetic Information
By signing this Authorization for the Release of Genetic Information (“Authorization”), I authorize the following:
- I authorize Genelex Labs, LLC, the laboratory performing my genetic tests, to disclose the results of my genetic markers for FTO (the body fat gene), MC4R (the appetite gene), and DRD2 (the cravings gene) along with my demographic information, including my name, date of birth, and contact information (collectively, “Genetic Information”) to Newtopia, Inc., 4101 Yonge Street, Suite 706, Toronto, ON M2P1N6, for use in connection with the Newtopia Wellness Program and for Newtopia to provide me with the results of my genetic tests.
- I authorize Newtopia, Inc., its workforce, subsidiaries, subcontractors, agents and affiliated entities (collectively, “Newtopia”) to disclose my Genetic Information, to my Newtopia Coach, and the provider organization approving my eligibility for genetic testing.
- I authorize Newtopia to share my demographic information and the fact that I obtained a genetic test (without the genetic test results) with my health plan for payment purposes.
- I authorize Newtopia to use and disclose to third party researchers my Genetic Information without information typically used to identify me (e.g., name, address, date of birth) for purposes of conducting future genetic and scientific research. I understand that the results of such research will not be shared with me; may be published in a manner that would not identify me; and that I will not receive any financial benefit from such research or any products or services resulting from such research.
- I understand that Newtopia will never share my genetic testing results with my employer.
- I understand that once my Genetic Information has been disclosed, federal privacy laws may no longer protect my Genetic Information. I understand that this Authorization is voluntary and that my treatment, payment for treatment, enrollment or eligibility will not be conditioned on whether I refuse to sign this Authorization. If I do not sign this Authorization, however, I may not be able to participate in certain related aspects of the Newtopia Program.
- I understand that I may revoke this Authorization at any time and for any reason by writing to Newtopia at email@example.com. I understand that my revocation will not be effective for information already used and disclosed in reliance on my Authorization. By signing this Authorization, I authorize Newtopia to retain my Genetic Information until the expiration date of this Authorization, until I revoke this Authorization, or until I request that my Genetic Information be destroyed.
- This Authorization will expire as of the date on which I have graduated from the Newtopia Program, or am no longer covered under my employer’s health benefit plan, unless authorization is revoked by me or an earlier expiration date is required by applicable law. I understand that I am entitled to receive a copy of this Authorization once it has been signed.