I acknowledge that the information I've given is accurate and complete.
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 SARS-CoV-2, the virus causing COVID-19.
2. I authorize any employee or agent of the Laboratory to disclose the above-described information to TouchCare LLC (“TouchCare”).
3. The purpose of this disclosure is to allow TouchCare to quickly provide me with my test results for the presence of (Covid-19) and provide me with any relevant information concerning my test results.
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 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 TouchCare).
8. The information disclosed as a result of this authorization may be subject to redisclosure by the recipient and 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. Because of the ongoing public-health crisis, it may be necessary for The Laboratory and TouchCare 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. I have read and understood 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 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.
