Consent
I hereby authorize
- Find My Lab Testing (FMLT)
- Lab Testing API Inc. (with its affiliates and staff, “Lab Testing API Inc.”)
- Lab Testing API Inc. chosen Physician network including its physicians, their staff, agents and designees, and the laboratories that perform services requested by or consented by me to use and disclose health information about me in the manner and for the purposes stated below.
This authorization applies to the use and disclosure of the following information about me: all information in requests(s) submitted by me or about me with my consent and the laboratory test values/results/information which are the result of the request(s) so submitted.
For the avoidance of doubt, I specifically authorize the transfer and release of this information to, between, and among myself and the following individuals, organizations, and their representatives:
- Find My Lab Testing (FMLT) and its affiliates, their staff, and agents;
- Lab Testing API Inc. and its affiliates, their staff, and agents;
- Lab Testing API Inc. chosen Physician Network and its affiliates, physicians and their staff and agents;
- The designated physician of record and its staff, agents, and designees;
- The applicable laboratory of record and its staff and agents; and
- Certain providers for the purposes herein, and as required or permitted by law.
The information which is the subject of this authorization will be used or disclosed for the following purposes:
- to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving a laboratory request; reviewing, processing, and delivering the laboratory test value(s)/result(s));
- for treatment, health care operations, and payment services;
- to provide me with information and materials on treatment alternatives, health-related offerings and services, and products that may assist me with health, wellness, and overall care or be of interest to me; and
- to conduct statistical research studies, and as required or permitted under state and federal laws. Remuneration may be received in exchange, therefore.
I may opt to not have my personal information disclosed for some purposes above with prior written notice to Find My Lab Testing (FMLT), Lab Testing API Inc., and its chosen Physician Network as applicable, as set forth below. I understand that such an opt-out may affect the services I have voluntarily elected.
This authorization evidences my informed decision to allow the release of the information to the parties referenced in this authorization. This authorization is effective immediately and will expire ten 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 if permitted by law. Lab Testing API Inc. or its chosen Physician Network may receive payment or other remuneration related to the use and disclosures herein.
I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by certain privacy laws. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization have acted in reliance upon this authorization.
My written revocation must be submitted to, as applicable, Lab Testing API Inc. at:
c/o Lab Testing API Inc.
2810 N Church St #30986
Wilmington, Delaware
19802-4447, US
Attn: Michelle Chilcott
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