I hereby grant Konsu Health, LLC. (“Konsu Health”) (formerly Ready Health, LLC) access to my protected health information. This includes protected health information which is reasonably related to COVID-19 testing. The purpose of this disclosure is to allow Konsu Health to have the information necessary to provide testing services.
I hereby authorize Konsu Health to disclose my protected health information to the provider performing my collection procedure and to other third party contractors, including laboratories performing the testing. The only protected health information that Konsu Health may disclose to my provider or to such contractors is that which is reasonably related to COVID-19 testing. The purpose of this disclosure is to allow my provider and the relevant contractors to have the information necessary to provide testing services.
I understand that the information used or disclosed to Konsu Health or my provider may be subject to re-disclosure and may then no longer be protected by federal privacy regulations.
I hereby authorize Konsu Health and its third party contractors to send my COVID-19 test results to me by email. This may include protected health information. The purpose of this disclosure is to ensure access to results.
I may revoke the authorization permitting my provider to disclose my information to Konsu Health by notifying my provider in writing of my desire to revoke it. I may revoke the authorization permitting Konsu Health to disclose my information to my provider by notifying Konsu Health in writing of my desire to revoke it. However, I understand that any action already taken by my provider or Konsu Health in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year after the date of signature below. I acknowledge and agree that Konsu Health and its relevant contractors may retain my protected health information as long as they retain or store any of my samples.
I understand that my authorization is voluntary and I am not required to sign this form. My failure to sign this form will not otherwise affect my medical treatment. However, I further understand that my Konsu Health cannot provide services without this authorization.
I have read and understand the above information. I have received a copy of this form and I am either the patient or am authorized to act on behalf of the patient to sign this document, thus verifying authorization for the use or disclosure of the protected health information under the above stated terms.