By signing this form, I understand the following:
The laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I have the right to withhold or withdraw my consent to the use of telemedicine duirng my care at any time, without affecting my right to future care or treatment. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be in other areas, including out of state.
I acknowledge that I have been informed of my rights under the Health Information Protection and Portability Act (HIPAA), I understand that I may request copies of this information and rights any time.
I hereby authorize ARK LA Tex Covid Testing Solutions, to use HIPAA-compliant telecommunication for evaluating, testing and diagnosing my medical conditions. I do understand that this information will be shared with Wiley College.