HIPPA Privacy Authorization
HIPAA PRIVACY AUTHORIZATION
Purpose: This authorization allows our partner healthcare providers and laboratories to share your protected health information, including results of test(s) you order, with us.
BY CLICKING ON THE “I HAVE READ AND ACCEPT THE HIPAA AUTHORIZATION” BUTTON ON THE ACCOUNT CREATION PAGE ON THE WWW.CARDIOMETABOLIQ.COM WEBSITE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS HIPAA PRIVACY AUTHORIZATION I HEREBY AUTHORIZE ALL TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH CHOOSE HEALTH (“ COMPANY”), TO USE AND DISCLOSE HEALTH INFORMATION ABOUT ME IN THE MANNER AND FOR THE PURPOSES STATED BELOW.
This authorization applies to the use and disclosure of the following information about me:
all information in request(s) submitted by me or for me with my consent, and the laboratory test values/results/information which are the result of such request(s).
I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees:
A. Company, B. applicable Accredited Labs, and C. Other Company partners for the purposes herein and as required or permitted by law.
This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, as permitted by law. I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization and understand that my refusal may affect the CardioMetaboliQ LLC provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.
I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company at: CardioMetaboliQ LLC, 187 Calle Magdalena, Ste 210, Encinitas, CA 92024 or by email at: email@example.com