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An annual blood draw is recommended to evaluate your health status. However, if you’re actively working on reducing risk factors for coronary artery disease and arteriosclerosis and/or diabetes, you can repeat it more frequently, usually every three months. This allows you to directly track results.
At present, laboratory services are not available to members outside the United States. Within the US, laboratory service such as ours is prohibited in NY, NJ, RI, MD and MA, and we have no Patient Service Centers in Hawaii.
Informed Consent For Laboratory Services
I hereby authorize PWNHealth, LLC (with its affiliates, “Company”), and www.myhealthypotential.com(Healthy Potentials), all applicable physicians, their staff and agents, and the laboratories that perform services requested by me (“Company Parties”) 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 requests(s) submitted by me and the laboratory test values/results/information which are the result of the request(s) so submitted.For 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: (a) Healthy Potentials and its affiliates, their staff and agents, (b) Company and its affiliates, and their staff and agents, (c) the designated Company physician of record and its staff and agents, (d) the applicable laboratory of record and its staff and agents, and (e) certain providers for the purposes herein, and as required or permitted by law.The information which is the subject of this authorization will be used or disclosed for the following purposes: (a) facilitate and execute the services requested by me for my benefit (including receiving, reviewing and approving a laboratory request; reviewing, processing and delivering the laboratory test value(s)/result(s)); (b) for treatment, health care operations and payment services; (c) 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; and (d) conduct statistical research studies, and as required or permitted under state and federal laws. Remuneration may be received in exchange therefor. I may opt-out to have my personal information disclosed for some purposes above with prior written notice to the Company noted below – I understand that such opt-out may affect the services I have voluntarily elected.This authorization evidences my informed decision to allow release of the information to the parties referenced in this authorization. This authorization is effective immediately and will expire ten years after the date of this authorization.
Upon my written request, I may inspect or copy the information stated herein to be used or disclosed, if permitted by law. Company Parties may receive payment or other remuneration related to the use and disclosures herein.
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 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 the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization have acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:
123 West 18th Street
New York, New York 10011
If signed by someone legally authorized to represent the individual, please describe that authority and attach document(s) evidencing that authority.
By acknowledging this authorization electronically, I agree to its terms and representations.
By purchasing this product you agree to the above Informed Consent for Laboratory Services policy.
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