Patient Authorization for Use and Disclosure of Protected Health Information
Thank you for using Chief Labs please be aware that by accessing this website,
you agree to be bound understanding fully in its entirety Chief Labs Patient
Authorization for Use and Disclosure of Protected Health Information.
I authorize my health care providers, including University Services,
its physicians and its staff and the laboratories that run medical
tests for me to use and/or disclose certain protected health information about
me to Chief Labs for the purposes state below.
This authorization applies to the following protected health information
about me: the laboratory requisition submitted by Chief Labs and the laboratory
test values which are the result of the laboratory test(s) requested in the requisition.
For avoidance of doubt, I specifically authorize the transfer of this information
between and among myself and the following Participants, organizations and their
representatives: i) Chief Labs, ii) University Services staff and physician of record, and iii) the reference laboratory of record.
I understand that University Services physician of record may be required to receive
my lab test results before I do, and that this physician's authorization to release
those results to Chief Labs may also be required before I receive my results.
The protected health information will be used or disclosed for the sole purpose
of complying with the state and federal laws which may require a physician or
their agent to: 1) review and approve a laboratory requisition; and 2) review the
laboratory test results. This review may be conducted for any reason, including
in the event laboratory values, which are outside of normal ranges, require the
physician or its agent to contact me.
The purposes outlined above are provided so that I can make an informed decision whether to allow release of the information to
the parties referenced in this authorization. This authorization will expire one year after the date of this authorization.
I understand that I have a right to receive a copy of this authorization. I understand that the sole purpose of the laboratory
test is to generate the results of the tests that I and the Health Service Affiliate(s) have
requested, and the laboratory tests will not be requisitioned unless I sign this authorization.
I have the right to refuse to agree to this authorization. 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:
Post Office Box 9100
Fredericksburg, VA 22403
I will receive a copy of Patient Authorization for Use and Disclosure of Protected Health Information via email once
I have placed an order with Chief Labs. My electronic signature of authorization is represented by the purchase I have made
with Chief Labs. By accepting and using the requisition sent to me by Chief Labs I also agree to all of the stated above.