HIPPA Authorization Form
I hereby grant Cell Vault, Inc. (“Cell Vault”) 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 Cell Vault to have the information necessary to provide testing services.
I hereby authorize Cell Vault 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 Cell Vault 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 Cell Vault or my provider may be subject to re-disclosure and may then no longer be protected by federal privacy regulations.
I hereby authorize Cell Vault 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 Cell Vault by notifying my provider in writing of my desire to revoke it. I may revoke the authorization permitting Cell Vault to disclose my information to my provider by notifying Cell Vault in writing of my desire to revoke it. However, I understand that any action already taken by my provider or Cell Vault 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 Cell Vault 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 Cell Vault 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.