1. Purpose of This Consent

You are requesting genetic counseling as part of our Goldilocks Screening Plan, which provides personalized, risk-stratified breast cancer screening recommendations. To support you through this process and any related care, Appalachian Medical Professionals offers Patient Navigation Services (also called Principal Illness Navigation or PIN services). These services help patients with serious or high-risk health conditions—such as elevated breast cancer risk or a cancer diagnosis—navigate the healthcare system more effectively.

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2. What Patient Navigation Services Include

A trained navigator (under the supervision of your doctor or advanced practice provider) will:

• Help coordinate appointments for genetic counseling, testing, imaging, or follow-up care

• Explain results in plain language and connect you to resources

• Identify and address barriers to care (e.g., transportation, insurance, scheduling, emotional support)

• Assist with referrals to specialists or community services

• Provide education and self-advocacy tools tailored to your risk and screening plan

• Track progress and communicate with your care team

These are non-clinical support services designed to improve timely access to care and reduce delays. They are provided in addition to your regular medical care.

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3. Important Information About These Services

• An initial evaluation and management (E/M) visit with your provider is required before navigation services begin.

• Services are billed monthly using Medicare’s Principal Illness Navigation codes (e.g., G0023 for the first 60 minutes per month, G0024 for each additional 30 minutes) when medically appropriate for a serious or high-risk condition expected to last at least 3 months.

• Cost-sharing applies: You may be responsible for copayments, coinsurance, or deductibles according to your insurance plan (including Medicare). We will explain your estimated costs if requested.

• Your navigator works under the direction of your provider and follows all privacy laws (HIPAA).

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4. Your Consent

By signing the bottom of the AMP Genetic Pre-Screening Test Form, I confirm that:

• I have read and understand the description of Patient Navigation Services.

• I agree to receive these services in connection with my genetic counseling request and the Goldilocks Screening Plan.

• I authorize Appalachian Medical Professionals and its navigators to coordinate my care, share necessary protected health information with other providers or resources (as allowed by law), and bill my insurance (including Medicare) for these services.

• I understand I can refuse or stop these services at any time without affecting my other medical care.

• I understand consent must be renewed annually.