HIPAA Form
1. By signing my name below, I authorize P23 Labs, LLC (“Laboratory”) to use and disclose the following information related to my care: my first and last name, date of birth, and the results of my laboratory testing conducted by Laboratory, including test results for the presence of the novel coronavirus (Covid-19).
2. I authorize any employee or agent of the Laboratory to disclose the above-described information to TouchCare LLC (“TouchCare”) who will then disclose this information to (“My Employer”).
3. The purpose of this disclosure is to allow My Employer to conduct medical surveillance relating to preventing the spread of the novel coronavirus.
4. This laboratory test has been approved by the United States Food and Drug Administration (“FDA”), however, I understand that this test alone may not be sufficient to detect or rule out the possibility that I have been exposed to or are infected with COVID-19. I should carefully monitor my own symptoms, and, notwithstanding the results of any testing, I must stay home and consult with my physician if I experience symptoms of COVID-19.
5. In order to collect samples for laboratory testing, the Laboratory utilizes an FDA EUA Oral Fluid Collection device approved for self-collection, which can be completely self-collected in most cases. FDA EUA Covid-19 Diagnostic Test which facilitates the detection of nucleic acid from SARS-CoV-2 in order to determine the presence of Covid-19 in the sample, which indicates whether I have tested positive or negative for Covid-19.
6. I understand that if I do not sign this authorization, I will not receive laboratory testing or related services from Laboratory at this time.
7. This authorization will be effective for one (1) year from the date signed below. I have the right to revoke this authorization at any time by notifying Laboratory at P23 Labs, LLC, 7426 Hodgson Memorial Drive Savannah, GA 31406. My revocation of this authorization must be in writing. My revocation will not be effective to the extent Laboratory has already relied upon this authorization (by disclosing information to My Employer or TouchCare).
8. I understand that My Employer, acting as an employer, is not subject to the federal HIPAA privacy rules. The information disclosed as a result of this authorization may no longer be protected by the federal HIPAA privacy rules.
9. I have the right to discuss the proposed testing with my physician, to learn about the purpose, potential risks and benefits of any testing. Based upon my test results, if I am denied entry to My Employer, I should contact a physician or other medical professional for advice. Because of the ongoing public-health crisis, it may be necessary for The Lab, TouchCare and My Employer to share the results of my test with public health authorities. By signing below, my consent to the disclosure of such information as requested, recommended or required by federal, state, and local public health authorities.
10. By signing below, I agree to release and waive any claim arising from my selection to receive this voluntary screening, that may arise against My Employer, TouchCare and the Laboratory. Additionally, I agree to release and waive any claim that might arise against My Employer, TouchCare, the Laboratory and its designated medical providers and staff members for any risks, side effects, or complications resulting from the testing.
11. I have read and understand the content of this Authorization to Use and Disclose PHI. This authorization correctly describes my request of the Laboratory. I understand that by signing this form, I am voluntarily giving my permission for the Laboratory to use and/or disclose my PHI to My Employer and TouchCare. I understand that I have the right to revoke this authorization at any time by providing a signed, written notice of such revocation to the Laboratory, except to the extent the authorization has already been relied upon. I understand that the information released pursuant to this authorization may no longer be protected by law or regulation and may be redisclosed by the recipient.
