HIPAA Authorization
(The purpose of this HIPAA Authorization (“Authorization”) is to request your written permission to allow Pinnertest to use and disclose certain protected health information (“PHI”). Your decision to e-sign this Authorization is entirely voluntary. We do not condition medical treatment on the signing of these Authorizations. However, you must e-sign the Authorization if you would like to participate in this particular service.)
I authorize Pinnertest to use and disclose my PHI as described below for the purpose(s) described below. I understand Pinnertest will not further use or disclose the PHI described on this Authorization unless another Authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. The PHI disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected. I hereby release Pinnertest from any/all liability that may arise from the release of my PHI, as described herein. Description of information to be used or disclosed: Health information provided by me related to my Pinnertest test request. PHI to be used for the following purpose: To be provided directly to Pinnertest physician so that a determination as to the appropriateness of my test request may be evaluated.
I understand that this Authorization will terminate/expire upon me providing a revocation of authorization to Pinnertest by contacting customerservice@pinnertest.com, or by U.S. mail at 8400 River Rd, Suite 2D, North Bergen, NJ, 07047. I understand that I may revoke this Authorization at any time, except to the extent that a disclosure has already taken place pursuant to this Authorization. I understand that once Pinnertest receives my revocation of this Authorization, Pinnertest can only use and disclose my PHI as permitted by its Privacy Policy and as permitted or required by law.