to consult a licensed medical provider for interpretation, analysis, evaluation, and explanation of my test results. I understand
that neither MY LAB TEST, or it’s ordering medical provider, will analyze, evaluate, critique, review or otherwise interpret the results of said tests. I agree that MY LAB TEST, its employees, employed medical providers, or any agent for the business shall not be liable for any claims including, but not limited, any claim arising out of or related to, inaccurate, uninterrupted, misinterpreted, or results not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action.
I certify that I will not seek to be reimbursed by Medicare, Medicaid, Tricare or any other government insurer/payer for the tests performed. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by MY LAB TEST at my request.
I understand that the blood and/or urine tests performed at MY LAB TEST are done at my request to be screened through either blood and/or urine testing. I further understand that a licensed medical provider under state law to order such testing will do so. I also understand that the actual testing will be performed either on-site or performed by a third party laboratory, certi ed to perform such testing on my urine and/or blood specimen collected by MY LAB TEST. I understand and agree that MY LAB TEST will report the results of the testing directly to me, my physician, or any health professional I request. I consent and authorize that such disclosure may be made by fax, email, mail or by direct pick-up. I understand and agree that the services provided by MY LAB TEST and the tests results from the lab will be maintained as con fidential, protected health information by MY LAB TEST as required by federal and state law.
I understand that the test results may become part of my medical record. I also understand that an insurance company may discover the results of this testing by obtaining a copy of my medical record in accordance with the terms of my insurance policies. I hereby consent to the release of my urine and/or blood test results by MY LAB TEST to me in the manner I have chosen in the box below and my physician or any other healthcare provider I designate. I understand that my test results will only be provided to other third parties upon my express consent.
All of the above has been discussed with me and I have had an opportunity to have any questions answered that I may have regarding my rights to privacy by an employee of MY LAB TEST. I have received a copy of Notice of Privacy Practices, as required by HIPPA from MY LAB TEST or have chosen not to receive a copy.
CUSTOMER AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION VIA E-MAIL.
I authorize MY LAB TEST to disclose the protected health information, my lab results, to the e-mail I have indicated. This authorization is only e fective for the visit date (”Today’s Date”) listed on this authorization form. You must submit a new authorization form at each visit to MY LAB TEST if you wish to receive your laboratory test results by e-mail.
I have the right to revoke or terminate this authorization by submitting a written request to MY LAB TEST. This can be done in person, mail or by email at info@mylabtest.net.
RE-DISCLOSURE: I understand that MY LAB TEST has no control over who may have access to the e-mail address I have listed to receive my protected health information. The information disclosed and future disclosure are not the responsibility of MY LAB TEST.
I, the undersigned, authorize MY LAB TEST to disclose or provide protected health information (laboratory test results only) directly to me at the e-mail address I have provided below. I also understand that it is my responsibility to notify MY LAB TEST of any change in this information. Any disclosure on e-mail is subject to the re-disclosure statement within this authorization.
