HIPAA Authorization and Waiver of Liability
The undersigned has requested a COVID-19 and/or other respiratory pathogen diagnostic test for the undersigned and/or the minor child of the undersigned at the drive-through ACCU Testing location located at 122 Slade Ave. Baltimore, Maryland 21208 or other location.
The undersigned hereby releases from any liability ACCU Testing, all of the individuals performing the testing swabs, the STAR-K Kosher Certification, Inc., and any other entity involved in hosting the ACCU Testing COVID-19 Testing, and all of their respective officers, directors, employees and agents.
The undersigned authorizes ACCU REFERENCE MEDICAL LABS and ACCU Testing, Dr. Yosef Levenbrown, Dr. Julian Jakobovits and any other healthcare provider I designate as a recipient of the protected health information referenced herein.
Effective Period: This authorization for release of information covers the period of healthcare from 8/1/2020 TO 12/31/2023.
Extent of Authorization: The undersigned authorizes the release of his/her complete health record.
This medical information may be used by the person the undersigned authorizes to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as the undersigned may direct.
The undersigned understands that the undersigned has the right to revoke this authorization, in writing, at any time. The undersigned understands that a revocation is not effective to the extent that any person or entity has already acted in reliance on this authorization or if the undersigned's authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
The undersigned understands that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.