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Authorization for Use and Disclosure of Personal Information
This authorization allows our partner healthcare consultants and laboratories to share certain personal information, described below, including results of test(s) that you order, with us.
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 hereby authorize the transfer and release of this information to the following individuals/organizations and their representatives, affiliates, staff, agents, and designees: (a) Company; (b) applicable Health Consultants and Labs; (c) the web services controlled and/or provided by the parties and the Company, and (d) other Company partners for the purposes herein and as required or permitted by law.
I hereby acknowledge that my assigned Health Consultant is not acting as my healthcare provider to provide medical services.
The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) to conduct statistical research studies using de-identified test results; and (c) as required or permitted under applicable state and federal laws. I may opt to not have my personal information used or disclosed for some of the purposes above. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive.
This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. This authorization is effective immediately upon sending in my sample or electronically accepting the authorization page, and will expire five (5) years after the date of this authorization. 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 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 using the contact information below.
Written revocation of this authorization must be sent to:
STAT Medical LLCC/O Frederick J. Berger, Registered Agent7700 Bonhomme Ave, 7th Fl.St. Louis, MO 63105
You may also email email@example.com your indication to revoke this Authorization & Consent. STAT will notify all 3rd parties within 72 hours that have access to the personal information that the authorization has been rescinded.
I understand that this authorization may be accepted by someone legally authorized to represent me.
Informational Purposes Only
The test results and any follow-up are for personal use and informational purposes only, and do not constitute treatment or the diagnosis of any condition, disease or illness. As with any test, there is a potential for a false positive or false negative result.
Follow up with my physician
You are solely responsible for forwarding your test results to your primary care or other personal physician and for initiating with your physician any care, diagnosis, medical treatment or to obtain an interpretation of the laboratory test results.
BY CLICKING ON THE “I HAVE READ AND ACCEPT THE AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION” BUTTON ON THE ACCOUNT CREATION PAGE ON THE STATMEDICALLLC.COM WEBSITE AND/OR BY SENDING IN MY SAMPLE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS AUTHORIZATION FOR RELEASE AND I HEREBY AUTHORIZE MY DESIGNATED HEALTHCARE CONSULTANT AND THE TESTING LABORATORIES, INCLUDING THEIR STAFF AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH STAT MEDICAL LLC (“COMPANY”), TO USE AND DISCLOSE PERSONAL INFORMATION ABOUT ME IN THE MANNER AND FOR THE PURPOSES STATED BELOW.
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