I understand that test results prepared by MYLABTEST will be reported to me, in the manner I have chosen in the box below. I further understand that it is my responsibility to consult a licensed medical provider for interpretation, analysis, evaluation, and explanation of my test results. I understand
that neither MYLABTEST, or it’s ordering medical provider, will analyze, evaluate, critique, review or otherwise interpret the results of said tests. I agree that MYLABTEST, 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 MYLABTEST at my request.
I understand that the blood and/or urine tests performed at MYLABTEST 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 MYLABTEST. I understand and agree that MYLABTEST 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 MYLABTEST 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 MYLABTEST 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 MYLABTEST. I have received a copy of Notice of Privacy Practices, as required by HIPPA from MYLABTEST or have chosen not to receive a copy.
CUSTOMER AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION VIA E-MAIL.
I authorize MYLABTEST 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 MYLABTEST 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 MYLABTEST. This can be done in person, mail or by email at info@mylabtest.net.
RE-DISCLOSURE: I understand that MYLABTEST 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 MYLABTEST.
I, the undersigned, authorize MYLABTEST 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 MYLABTEST of any change in this information. Any disclosure on e-mail is subject to the re-disclosure statement within this authorization.
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