HIPAA PRIVACY AUTHORIZATION
Purpose: This authorization allows us to share information you provide to us with our partners and allows our partner healthcare providers and laboratories to share your protected health information, including the results of test(s) you order with us.
BY CLICKING ON THE “I AGREE TO 4U HEALTH CONSENT & HIPAA PRIVACY AGREEMENT” BUTTON OF THE 4U HEALTH, INC. (“COMPANY”) WEBSITE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS HIPAA PRIVACY AUTHORIZATION AND I HEREBY AUTHORIZE ALL HEALTH CARE PROVIDERS, INCLUDING THEIR PHYSICIANS STAFF AGENTS AND DESIGNEES (“HEALTH CONSULTANTS”), AND THE TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS, AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH 4U HEALTH, INC., 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 request(s) submitted by me or for me with my consent and the laboratory test values/results/information which are the outcome of such request(s).
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, affiliates, staff, agents, and designees: (a) Company; (b) applicable Health Consultants and Labs; and (C) other Company partners for the purposes herein and as required or permitted by law.
The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) for treatment, health care operations and payment services; (c) to provide me with information and materials on treatment alternatives, health-related offerings and services, and products which may assist me with health, Wellness and overall care or be of interest to me; (d) to conduct statistical research studies; and (e) as required or permitted under applicable state and federal laws. I authorized the use of my personal information for marketing purposes, including providing information about products and services that may be of interest to me.
I may opt to not have my personal information used or disclosed for some of the purposes referenced herein. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive.
This authorization is evidence of my informed decision to allow the release of my information to the parties referenced herein. This authorization is effective immediately and will expire 10 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, as permitted by law.
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 and understand that my refusal may affect the services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.
I may revoke this authorization in writing at anytime. I understand that my revocation will not affect any use or disclosure already taken and reliance upon this authorization. My written revocation must be submitted to Company at: 4U Health, Inc., PO Box 100083, Pittsburgh, PA 15233; Email firstname.lastname@example.org.
SPECIAL AUTHORIZATION FOR TESTING PROVIDED BY OR IN CONJUNCTION WITH ORGANIZATIONS
I understand that this authorization may be accepted by someone legally authorized to represent me, as permitted under applicable state and federal laws.
If testing is being provided to you by an organization or in conjunction with an organization (e.g. a third party business or school) on either a voluntary or mandatory basis, then the following additional statements apply and to the extent inconsistent, supersede other provisions on this form. Your acceptance of this HIPAA Privacy Authorization form means you have read, understood and agree to the following:
HEALTH CONSULTANTS REMOTE CARE SERVICES: TELEHEALTH CONSENT NOTICES & ACKNOWLEDGEMENTS
- Results from testing, as well as information you provide during registration will be shared by Company, health consultants, and Labs with the organization providing/in conjunction with the testing (e.g. a third party business or school) and entities that provide related support services to the organization.
- Your results and information may be shared to facilitate treatment, for health care operations, and for public health activities and for purposes related to the other organizations’ business, including biomarker health status. We will only share the minimum amount of information necessary for these purposes.
- You can opt out of receiving email marketing communications from the company through unsubscribe links available on all such marketing communications.
- You can opt out of receiving text message marketing communications from the company by replying stop to all such marketing communications.
Purpose: This authorization allows our health consultant partners to access your data to provide physician oversight, review and ordering of your testing and to contact you explain results and /or to provide consultation, counseling, and prescriptions where applicable.
BY CLICKING “I AGREE”, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT CLICK “I AGREE”, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
I agree to receive the services provided by AKOS MD, LLC and certain other affiliated professional entities they may utilize and or control (collectively, “Akos”, “we”, or “us”) relating to ordering laboratory tests (“Tests”), including, without limitation, ordering of Tests, Test review services, testing, receipt of Test results (“Results”), physician consultations via Tele medicine (‘Consults”), physician oversight and/or care coordination, customer support or counseling and any other related services provided by AKOS or its service providers and partners (the “Services”). All clinical Services, including Services provided by physicians and/or their physician supervised designees, will be provided through AKOS VIRTUAL CARE or their affiliated professional entities.
If you have ordered an HIV test (including as part of a panel), please also review the Informed Consent to Perform HIV Testing immediately following this General Informed Consent.
I acknowledge and agree to the following:
- I am the individual or guardian who will provide the sample for the Test(s) that I am ordering.
- I am at least 18 years of age.
- I have read and understand the information provided about the Test(s) that I am requesting at the website where I am requesting the Test(s).
- In order to utilize the Services, I must provide an appropriate sample for the Test(s), which may include a blood, urine, saliva, tissue, or other sample.
- The information I provided in connection with the Services is correct to the best of my knowledge. I will not hold AKOS or it's health care providers nor 4U Health, Inc. responsible for any errors or omissions that I may have made in providing such information.
- My health information and results may be shared with other AKOS health care providers, including physicians, physician supervised counselors and support staff, and other affiliated AKOS designees for the purposes of providing care to me.
- The Services do not constitute treatment or diagnosis of any condition, disease or illness, except for Consults for Treatment Conditions described below.
- While AKOS and the laboratories implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive or false negative result.
- I agree to contact 4U Health, Inc. if I do not receive notice of Lab’s receipt of my sample, with five (5) days after mailing the sample.
- I agree to contact the AKOS Care Coordination Team if I do not receive results within twenty-one (21) days after my sample is received by the testing laboratory.
- I am responsible for checking my email for results notification in logging onto my account to view my results when available.
- If I receive an abnormal result on a Test, I understand AKOS Care Coordination team will attempt to call me to review the results, and or send me an email to initiate a Telehealth Consultation or care coordination encounter, to offer education and explain the next steps I should take. AKOS’ Care Coordination Team may leave me a voicemail but will not include my Test results in any voicemail message. I also understand that if I am not able to be reached, AKOS’ Care Coordination Team shall ensure a follow-up email is sent to the email address I provided when I purchased my test (the communication will not include my test results). If I receive an abnormal result in of not connected with AKOS’ Care Coordination Team, I understand that I should not delay following up with my personal physician or other qualified licensed health care provider.
- I certify that throughout the duration of the Services I receive, including my Consult, I will be physically present in the state I provided on 4U Health’s Site when I registered the Test Kit or if in another state, I shall notify AKOS.
- I am responsible for forwarding any results to my primary care or other personal physician and for initiating follow up with such physician for care, diagnosis, medical treatment, or to obtain an interpretation of the Results.
- I understand that I reserve the right to have any Test Result, whether positive or negative, confirmed by seeking medical care from anyother qualified licensed health care provider not associated with AKOS or the performing LAB that resulted my Test. If I choose to undergo confirmatory testing with another entity, I am responsible for all direct and indirect fees associated with said confirmatory testing.
- I will not make medical decisions without consulting a healthcare provider or disregard medical advice from my health care provider or delay seeking such advice based on information as a result of the use of the Services.
I understand Services, including Consults, are deliverd by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means including the electronic transmission of personal health information. I also understand that:
- An AKOS physician will determine whether or not Test(s) and Services, including any treatment, are appropriate for me.
- For Consults for Treatment Conditions, the scope of services will be at the sole discretion of the physician treating me, with no guarantee of diagnosis, treatment, or prescription. The physician will determine whether or not the condition being diagnosed and or treated or the Services being rendered are appropriate for a Telehealth encounter. The physician administering my Consult may advise for confirmatory testing and/or follow up with an in person licensed physician for definitive diagnosis and treatment, depending on my test results in conjunction with personal medical history, physical symptoms or lack thereof, or simply their best medical judgment.
- I have the right to withdraw my consent to use of Telehealth in the course of my care at anytime by contacting the AKOS Care Coordination Team by calling 1-844-900-2567, emailing email@example.com or by sending written notification to AKOS, P.O. Box 41638, Phoenix, AZ 85080.
- Any video feed from the Consult will not be retained or recorded by AKOS.
- I may need to see a health care provider in-person for diagnosis treatment and care.
- There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties. The use of technology also limits a physician's ability to perform a complete physical examination.
- There are alternative services, such as visiting in-person a primary care provider, an emergency room, or an urgent care facility: however, at this time I chose to proceed with the Services after weighing my personal risks and benefits.
I understand that if I have any questions before or after my Test, I can contact AKOS’ Care Coordination Team by calling 1-844-900-2567 or emailing firstname.lastname@example.org
I authorize AKOS to use the email address and phone number I provided to 4U Health at the time I purchased my Test(s), (or that I updated by contacting AKOS’ Care Coordination Team) to contact me in connection with the Services, including follow-up after a Consult. I am responsible for contacting AKOS’ Care Coordination Team by calling 1-844-900-2567 or emailing email@example.com to notify them of any changes to my mailing address, email address, phone number, or other information that I provided in connection with the Services.
I understand that testing is voluntary and that I may withdraw my consent for testing at anytime prior to the completion of the Test(s) by contacting AKOS’s Care Coordination Team by calling 1-844-900-2567 or emailing firstname.lastname@example.org.
I specifically authorized the transfer in the release of my information as described herein and in the Notice of Privacy Practices available to me when seeking and purchasing the Services, including my lab test Results and other identifiable health information, submitted by me or about me in connection with the Services, to, between and among myself and the following individuals, organizations and their representatives: (a) the company through which I purchased the applicable laboratory test and its affiliates, their staff and agents; (b) AKOS and its affiliates, and their staff, agents, and health care providers, including physicians, and (c) the laboratory conducting the laboratory testing services 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)), and as required or permitted by law.
I understand that I have a right to receive a copy of the above data disclosure 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 privacy laws. I have the right to revoke this authorization in writing at anytime, except that the revocation must be submitted to AKOS’ General Counsel at:
c/o General Counsel
P.O. Box 41638
Phoenix, AZ 85080