Tranquility Behavioral Health Patient Portal

2025 Consent Form for Neurocognitive and Additional Testing Services

What type of services are you seeking? * FIRST & LAST NAME: * Preferred Name D.O.B. * Phone * Email Address: * Home Address * SSN Preferred Pronouns * Occupation Highest Level of Education

Insurance Information

Insurance Name: * Policy Holder First & Last Name * Policy Holder D.O.B. * Subscriber ID Number: * Group Number * Relationship to Subscriber: * Do you have Secondary Insurance *

If answered yes, please input your Secondary insurance information

Secondary Insurance Name Subscriber ID Number Group Number

Purpose of Testing

At Tranquility Behavioral Health LLC, we provide specialized neurocognitive and additional testing services to enhance diagnostic accuracy and develop individualized treatment plans. The services include: 1. ADHD Testing 2. Autism Testing 3. Concussion Testing 4. Mild Cognitive Impairment Testing 5. Genesight Testing (Pharmacogenomic Analysis) 6. Nutrigenomic Testing These tests aim to provide valuable insights into your cognitive, emotional, and genetic profile, aiding in personalized mental health care.

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Nature of Testing

I understand that: ADHD, Autism, Concussion, and Mild Cognitive Impairment testing assess specific neurocognitive and behavioral domains. Genesight Testing evaluates my genetic compatibility with psychiatric medications. Nutrigenomic Testing identifies genetic markers that may influence nutritional and mental health outcomes.

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Financial Responsibility

I acknowledge that all neurocognitive testing services are elective and will not be billed to insurance. I accept full financial responsibility for the costs associated with these tests as outlined below. I also understand that fees associated with Genesight Testing cover only the cost of obtaining the sample for analysis, and the testing laboratory may bill my insurance for conducting the analysis. Nutrigenomic Testing is a completely out-of-pocket cost, and no portion will be billed to insurance.

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Confidentiality and Privacy

I understand that my personal and genetic information will remain confidential and will only be used for the purposes outlined in this consent form, in compliance with HIPAA regulations. Tranquility Behavioral Health LLC ensures the secure handling of all sensitive data, whether collected in person or remotely.

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Testing Options

I understand that neurocognitive testing services are available both in-person and remotely. For remote testing, I acknowledge that I must have access to an internet connection and a compatible device, such as a tablet, laptop, or desktop computer, to complete the testing process. Additionally, I understand that Genesight and/or Nutrigenomic Testing kits can be mailed to me once the collection fee has been obtained.

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Appointment Policy

I understand that payment must be made in full prior to scheduling an appointment for any neurocognitive or additional testing service. Appointments will not be confirmed until payment has been received. If payment is not made, the appointment will be canceled, and the slot will be released for other patients.

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Testing Limitations:

I understand that while these tests provide valuable information, they are not a definitive diagnostic tool and should be interpreted as part of a broader clinical assessment.

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Selection Acknowledgement

Fees for Testing Services * INITIAL *

By signing below, I confirm that I have read and fully understand the information provided in this consent form. I agree to proceed with the selected testing services and accept full financial responsibility. I further understand that: Neurocognitive testing services are elective and will not be billed to insurance. The Genesight Testing fee is for sample collection only, and the testing laboratory may bill my insurance for conducting the analysis. Nutrigenomic Testing is entirely out-of-pocket, and no portion will be billed to insurance. Remote testing requires access to an internet connection and a compatible device, and Genesight and Nutrigenomic Testing kits may be mailed once payment has been made. Payment must be made prior to scheduling the appointment, and appointments will not be confirmed without full payment.

Printed Signature * Date of Signing * HOW DID YOU HEAR ABOUT US? *