(C) The written authorization shall be a separate document, not attached to any other document, and shall not be more than one page.
(2) Any person who obtains, analyzes, retains, or discloses the genetic information of an individual shall use the following written form to obtain the authorization of the individual to whom the information pertains as required by subdivision (a) so that the individual may make a decision and provide direction regarding the use of his or her genetic information:
Important Privacy Choices
You have the right to control the use of your genetic information that you give to us. Please read the following information carefully before you make your choices below.
Important Information Regarding Your Genetic Information:
• The following types of people are authorized to obtain, analyze,
retain, or disclose your genetic information:_____________
• The following is the nature of the genetic information that you
are authorizing to be obtained, analyzed, retained, or disclosed:
___________________________________
• The following is the name of the person(s) authorized to obtain,
analyze, retain, or disclose your genetic information and his
or her function:____________________
• Your genetic information is being collected for the following
purpose:___________________________________
Unless you say otherwise as indicated below, your genetic
information may not be used for any other purpose.
• This authorization shall remain valid for as long as it takes to
carry out the purpose indicated above.
• The genetic information you give us will remain (____) identifiable or (____) will be made nonidentifiable.
• If we retain your genetic information, the following is the
manner in which it will be stored:______________________
Your Rights Regarding Your Genetic Information:
• You have the right to limit the purposes for which your genetic
information is used.
• Once we fulfill the purpose(s) you have authorized in this form,
we are required by law to destroy the genetic information and
sample that you provide us.
• You are permitted to limit access to your genetic information
to a certain person or persons.
• You are permitted to revoke this authorization at any time.
• You have a right to a copy of this authorization.
Your Choices Regarding Your Genetic Information:
(_) In addition to the purpose noted above, I authorize my
genetic information to be used for research purposes.
(_) In addition to the purpose noted above, I authorize my
genetic information to be used for commercial purposes.
(_) I would like to limit the purpose for which my genetic
information is authorized to be used in the following
way:___________
(_) I would like to limit access to my genetic information to the following person or persons:_______________________
(_) I would like to receive a copy of this authorization.
(_) I would like to revoke this authorization.
(h) Any person who obtains, analyzes, retains, or
discloses the genetic information of an individual shall comply with the following:
(1) The person may not obtain, analyze, retain, or disclose the genetic information for any purpose other than the purpose authorized by the individual to whom the information pertains.
(2) Once the specific purpose authorized by the individual to whom the genetic information pertains has been fulfilled, the individual’s genetic information and DNA sample shall be destroyed.
(3) The person shall permit an individual to limit access to his or her genetic information to a certain person or persons.
(4) The person shall permit an individual to revoke an authorization signed pursuant to subdivision (g) at any time.
(5) The person shall provide an individual who has signed an authorization pursuant to subdivision (g) with a copy of that authorization upon request.
(i) Genetic information may be obtained, analyzed, retained, or disclosed without the authorization provided in subdivision (g) in the following instances provided that the entity may obtain, analyze, retain, or disclose the information only for the specified purposes indicated, and any use for any other purpose is subject to the authorization required in subdivision (a):