Health Information Agreement
LabFinder may be referred to in this Agreement as “LF,’ “we,” “us,” “our” and “ourselves.” Any parent, guardian or other legal representative executing this Agreement represents and warrants he/she has the appropriate legal representative authority to do so on behalf of the patient or minor.
Tests are performed by an independent lab subscribers. The lab, its employees and agents are referred to as “Lab User(s)”.
This Agreement 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, my information as applicable. Accordingly LabFinder may:
Access, receive, transmit and store my Lab Services’ appointment information and test results from the testing lab and its employees or agents (“Lab Users”).
Share my Personal Information including Personal Health Information (PHI) with my physician or other clinician to the extent either (1) I provide LF with their contact information (using the name and contact information I provide or that they provide to LF or update with LF) and/or (2) they inform LF of my patient status, to enable them to order and/or otherwise review testing and/or test results of my Lab Services.
Use my 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 I schedule Lab Services via the LF Service, and to share with my physician/clinician.
Share the Personal Information including Personal Health Information (PHI) with the insurance provider I identify to LF, applicable plan administrator or their agent.
Vendors to handle the foregoing tasks for LF.
Share for public reporting if required by law.
I understand that signing this Agreement 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 Agreement 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 Agreement, 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 Agreement . This Agreement may also be revoked at any time by notifying LabFinder Privacy Office in writing at 969 Third Avenue, 3rd Floor, New York, NY 10022. If I revoke this Agreement, 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 Agreement form, I authorize the disclosure and use of my protected health information as described above, and that this information may be re-disclosed as required or permitted by law .