Consent – huntersville-28078

Consent Authorization

To expedite the process for your test, please answer the following questions.

Is this test for you? *

Yes

No

Customer Confirmation

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Customer authorization for disclosure of protected health information via e-mail

Please review the details below and confirm by entering your name in the customer signature field.

Customer Name *

Date of Birth *

I, the undersigned, authorize ANY LAB TEST NOW® to disclose or provide protected health information (laboratory results only) directly to me at the e-mail address I have provided below. I also understand that it is my responsibility to notify ANY LAB TEST NOW® of any change in this information. Any disclosure on e-mail is subject to the re-disclosure statement within this authorization.

E-mail Address *

I authorize ANY LAB TEST NOW!® to disclose the protected health information, my lab results, to the e-mail address I have indicated. This authorization is only effective for the visit date ("Today's Date") listed on this authorization form. You must submit a new authorization at each visit to ANY LAB TEST NOW® if you wish to have laboratory results sent to you by e-mail.

As stated in our Notice of Privacy Practice, I have the right to revoke or terminate this authorization by submitting a written request to the facility. This can be done in person or by mailing a request to the testing ANY LAB TEST NOW®.

RE-DISCLOSURE

I understand that ANY LAB TEST NOW® has no control over who may have access to the e-mail address I have listed to receive my protected health information.

The information disclosed will no longer be protected by the requirements of the Privacy Rule and future discloser is not responsibility of ANY LAB TEST NOW®.

Signature *

Typing your name will represent your signature

General Intake Consent

Customer Authorization for Disclosure of Protected Health Information via e-mail.

Name *

Date of Birth *

Gender *

Female

Male

Other

Address 1 *

Address 2

City *

State/Province/Region *

ZIP/Postal Code *

Country *

E-mail Address *

Phone Number *

Allergy information (Check all that apply)

Latex

Alcohol

Betadine

Other (Please specify)

I understand that test results reported by ANY LAB TEST NOW will be reported directly to me, in the manner chosen below. I further understand that it is my responsibility to consult my own medical doctor for interpretation, analysis, evaluation, and explanation of my test results. I understand that neither ANY LAB TEST NOW nor its ordering physician will analyze, evaluate, critique, or otherwise interpret the results of said tests. I agree that ANY LAB TEST NOW, its officers, shareholders, directors, employed physicians or its other agent or employee shall not be liable for any claims including, but not limited to, any claim arising out of or related to, inaccurate, uninterrupted, misinterpreted or results not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action. *

I certify that I will not seek to be reimbursed by Medicare, Medicaid, Tricare or any other government insurer/payer. I agree that I am personally financially responsible for the payment of fees for all tests ordered and collected by ANY LAB TEST NOW at my request. *

I understand that the laboratory tests performed at ANY LAB TEST NOW are done at my request. I further understand that a physician employee of ANY LAB TEST NOW who is licensed under state law to order such testing will do so. I also understand that ANY LAB TEST NOW is a collection facility and that the actual testing will be performed by a third-party laboratory, certified to perform such testing on the specimens collected by ANY LAB TEST NOW. I understand and agree that ANY LAB TEST NOW will report the results of the testing directly to me, my physician, or any health professional I request. I consent and authorize that such disclosure may be made by fax, by mail, or by direct pick-up. I understand and agree that the services provided by ANY LAB TEST NOW and the test results from the lab will be maintained as confidential, protected health information by ANY LAB TEST NOW as required by federal and state law. *

I understand that the test results may become part of my medical record. I also understand that an insurance company may discover the results of this testing by obtaining a copy of my medical record in accordance with the terms of my insurance policy(ies). I hereby consent to the release of my laboratory test results by ANY LAB TEST NOW to me in the manner, I have chosen below and my physician or any other healthcare provider I designate. I understand that my test results will only be provided to other third parties upon my express consent. *

I understand that all charges are final, and no refunds or chargebacks will be accepted. *

I have received a copy of Notice of Privacy Practices, as required by HIPAA from ANY LAB TEST NOW or I have chosen not to receive a copy. *

I have read and agreed to all the above terms. *

Customer preferred method of receiving results *

Portal

E-mail

US Mail

Pick Up

Fax

Do you want us to fax a copy to your doctor's office? *

Yes

No

Call me first when results are ready

Optional

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How did you hear about us?

Internet

Radio / TV

Print AD

Direct Mail

Walk / Drive By

Social Media

Personal Referral

Professional Referral

Other

Are you willing to rate your service if we send you an SMS or email?

Yes

No

Signature *

Typing your name will represent your signature

WELCOME

Consent Authorization

Customer Confirmation

Appointment details

Category Selection

Customer authorization for disclosure of protected health information via e-mail

RE-DISCLOSURE

General Intake Consent

Thank you for your interest in buying these test(s) for your child under the age of 12.