HIPAA Authorization

HIPAA Authorization for Use and Disclosure of Protected Health Information

This Authorization allows us to use and disclose your health information to provide in-home phlebotomy and laboratory testing services.

1. Authorization

I voluntarily authorize the use and disclosure of my Protected Health Information (PHI) as described below.

2. Information to Be Used or Disclosed

This Authorization applies to health information that may include, but is not limited to:

  • My name, date of birth, and contact information
  • Laboratory test orders and results
  • Specimen collection information
  • Appointment and service details
  • Billing and payment-related information

3. Purpose of Disclosure

My health information may be used or disclosed for the following purposes:

  • Scheduling and performing in-home specimen collection
  • Submitting specimens to laboratories for testing
  • Reporting laboratory test results to me
  • Care coordination, customer support, and quality assurance
  • Billing, payment processing, and required administrative functions

4. Parties Authorized to Use or Receive Information

My PHI may be shared with:

  • Licensed phlebotomists or healthcare professionals providing in-home services
  • Certified clinical laboratories performing ordered tests
  • Healthcare providers involved in my care, as applicable
  • Business associates who support operations and are required to protect my information

5. Right to Revoke

I understand that I may revoke this Authorization at any time by submitting a written request through the application or by contacting customer support. Revocation will not apply to information already used or disclosed.

6. Expiration

This Authorization will remain in effect until the earlier of:

  • Completion of the requested services, or
  • One (1) year from the date I provide consent, unless otherwise required by law

7. No Condition on Treatment

I understand that my decision to sign this Authorization is voluntary. However, failure to provide authorization may prevent the delivery of requested services.

8. Redisclosure

I understand that information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA.

9. Acknowledgment and Consent

By checking this checkbox or otherwise indicating my acceptance, I confirm that:

  • I have read and understand this Authorization
  • I am the patient or legally authorized representative
  • I authorize the use and disclosure of my health information as described above