This Authorization applies to all Dates of Service scheduled through the LabFinder Service. LabFinder is not a healthcare provider, clinical laboratory or diagnostic testing provider.
Purpose of Release:
I hereby authorize LabFinder and its designees to access, disclose and release, as applicable, the following:
We may access/receive transmittal of and store your Lab Services’ appointment information and test results from the Lab Users you schedule through the LF Services.
We may share your Personal Information including Personal Health Information (PHI) with your physician or other clinician to the extent either (1) you provide us with their contact information (using the name and contact information you provide or that they provide to us or update with us) and/or (2) they inform us of your patient status, to enable them to order and/or otherwise review testing and/or test results of your Lab Services.
We may use your Personal Information including Personal Health Information (PHI) for the purposes of insurance verification, determining eligibility, co-pay, deductible, co-insurance and/or cost-sharing obligations, and otherwise obtaining benefit plan information to share with the Lab User with which you schedule Lab Services via our LF Service, and to share with your physician/clinician. We may share the Personal Information including Personal Health Information (PHI) with the insurance provider you identify to us, applicable plan administrator or their agent. We may contract vendors to handle the foregoing tasks for us.
We may share your Personal Information including Personal Health Information (PHI) with your physician or other clinician to the extent either (1) you provide us with their contact information (using the name and contact information you provide or that they provide to us or update with us) and/or (2) they inform us of your patient status, in either case to enable them to order and/or otherwise review testing and/or test results of your Lab Services and to advise them of your appointment status.
I understand that the recipients of the information may benefit financially if I choose to utilize services through them.
I understand that signing this authorization is voluntary. My healthcare treatment and benefits (including payment rights and eligibility, as applicable) will not be affected if I do not sign this form. I am not required to use LabFinder to schedule my treatment. I understand that I may refuse to authorize the release of any personal or health information as described herein and that my refusal to sign and thereby consent to this release will prevent the disclosure of such information for such purposes, but will not affect the health care services I presently receive, or will receive, from third parties, though it may affect my ability to register with LabFinder and/or use LabFinder for the LF Services or particular functionality within the LF Services. I understand that I may get a copy of this form after I sign it.
I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, which may affect my ability to use LabFinder for the LF Services or particular functionality within the LF Services. If I do not revoke this authorization, it will expire when I de-activate my LabFinder account in accordance with mechanisms made available on the LabFinder website, and that re-activation may necessitate re-execution of this Authorization. This authorization may also be revoked at any time by notifying LabFinder Privacy Office in writing at 845 Third Avenue, 6th Floor, New York, NY 10022. If I revoke this authorization, I understand that it will not have any effect on actions that the above named recipients and other business associates, employees and/or professionals associated with them already took.
I understand that the information described, or some portion thereof, is protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I understand that by signing this authorization form, I authorize the disclosure and use of my protected health information as described above, and that this information may be re-disclosed if the recipient(s) described on this form are not required by law to protect the privacy of the information.