EFTA00540398.pdf

From: [email protected] To: Subject: Quest Diagnostics Authorization Confirmation Date: Thu, 29 Mar 2018 15:57:49 +0000 Dear ICaryna, We are emailing you confirmation of your authorization for Quest Diagnostics to release test results to the account according to the Authorization below. This authorization does not impact any arrangement that may be in place between you and your physician regarding the releasing of your lab results to your account. If you feel you may have received this message in error, please contact our customer support team at [email protected] for immediate assistance. PATIENT AUTHORIZATION TO SEND PROTECTED HEALTH INFORMATION (PHI) ELECTRONICALLY TO A PERSONAL HEALTH RECORD OR E-MAIL ACCOUNT I hereby authorize Quest Diagnostics to electronically send the results of laboratory tests performed on me by Quest Diagnostics from this date forward to my Electronic Account, which is either a Personal Health Record ("PHR") or e-mail account (the PHR or e-mail account being referred to as an "Electronic Account") which I have identified to Quest Diagnostics when I set up my Quest Diagnostics account. In addition, I understand that upon submitting this Authorization, any of my laboratory test results issued by Quest Diagnostics up to 60 days prior to the date of this Authorization may be sent to my Electronic Account. I understand that laboratory test results are considered, under the Health Insurance Portability and Accountability Act (HIPAA), to be "protected health information". This authorization is for purposes of submitting these laboratory test results to my Electronic Account. I understand that this Authorization will remain in effect for all new testing I receive from Quest Diagnostics, and it will expire when I notify Quest Diagnostics to stop sending my results to my Electronic Account in accordance with the "Revoke Authorization" terms provided below. I acknowledge that I have read the "Notice to the Patient" information included with this authorization. NOTICE TO THE PATIENT: The purpose of this Authorization is to allow Quest Diagnostics to disclose information to your Electronic Account, as set forth above. • Quest Diagnostics cannot condition its provision of services to you on the receipt of this Authorization, however if you do not complete this Authorization Quest Diagnostics will not honor your request that we send your information to the Electronic Account identified by you in this Authorization; • After authorizing release of your health information, a copy of this authorization will be emailed to you for your records. EFTA00540398  • The information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the party controlling the Electronic Account to whom the protected health information will be sent, and to the extent it has been disclosed to such party, your protected health information may no longer be protected by the privacy and security regulations of HIPAA, and you understand that you are relying on the privacy policy of such party with regard to how your protected health information is maintained by them; and • You have the right to revoke this Authorization at any time, in accordance with the "Revoke Authorization" terms provided below. • You understand that Quest Diagnostics can only send test results to you based on the ordering health care provider's inclusion of appropriate identifying information about you on the test order, and that if such information is missing, or not accurate, those test results will not be sent to your Electronic Account. State law requirements may also limit the electronic transmission of certain test results. Patient Authorization Revocation Process: To revoke your authorization for Quest Diagnostics to send your protected health information to your Electronic Account, you must login to MyQuestTM and select the following: 1. Options 2. Revoke My Authorization 3. Submit Revocation requests will be effective 10 days after they have been submitted to Quest Diagnostics, and Quest Diagnostics may not send your protected health information in accordance with this authorization after that date, except that after revocation if there is an amended test result of a prior test sent to you the amended test result will be sent to your Account. You further understand that any disclosure requests that are in process when you submit this revocation request may not be revoked. The contents of this message, together with any attachments, are intended only for the use of the person(s) to which they are addressed and may contain confidential and/or privileged information. Further, any medical information herein is confidential and protected by law. It is unlawful for unauthorized persons to use, review, copy, disclose, or disseminate confidential medical information. If you are not the intended recipient, immediately advise the sender and delete this message and any attachments. Any distribution, or copying of this message, or any attachment, is prohibited. EFTA00540399