- I understand that it is my responsibility to consult my own medical provider for interpretation, analysis, evaluation, and explanation of my test result. I understand that neither InOut Labs (a.k.a. labtestshop.com, titershop.com, or another public-facing brand of InOut Labs) nor its ordering physician(s) will analyze, evaluate, critique, review or otherwise interpret the result(s) of these tests. I agree that InOut Labs, its officers, shareholders, directors, contracted physicians, or its other agents or employees shall not be liable for any claims including, but not limited to, any claim arising out of the related to, inaccurate, un-interpreted, misinterpreted or result InOut Labs not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action.
- I certify that I am not a recipient of Medicare, Medicaid or any other government health insurance benefits, nor will I seek to be reimbursed by Medicare, Medicaid or any other government insurer/payor for the test(s) performed. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by InOut Labs at my request.
- I understand that the tests that I have selected to be performed by InOut Labs are done at my request. I further understand that a contracted physician of InOut Labs who is licensed under state law to order such testing will do so. I also understand that the actual testing will be performed by a third-party laboratory, certified to perform such testing on my specimen collected by InOut Labs, its contractor(s), a third party or myself. I understand and agree that InOut Labs will report the result of the testing directly to me or to those I designate. I consent and authorize that such disclosure may be made by fax, mail, secure web portal, direct pick-up or by email. I understand and agree that the services provided by InOut Labs and the test result(s) from the lab will be maintained as confidential, protected health information by InOut Labs as required by Federal and State law. Neither InOut Labs nor any of its service agents will provide specific medical advice that includes diagnosis and treatment about my lab results. This service does NOT in any way constitute a doctor / patient relationship.
- 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 the test results may become part of my medical record. I hereby consent to the release of my test results by InOut Labs to me in the manner I have chosen and my physician or any other healthcare provider or insurance company designate, or as otherwise required by law. I understand that, unless required by law, my test results will only be provided to other third parties upon my express consent.
- If I have ordered an STD test, and the result comes back positive, I agree to provide InOut Labs proof of treatment within 30 days of the test, as required by state law. I agree to provide the contact information of the medical provider as well as the treatment received. Many states’ Departments of Public health require that we report positive results for certain communicable diseases along with assurance the patient has been treated.
- All of the above has been discussed with me and I have had an opportunity to have any questions answered that I may have regarding my rights to privacy by an employee of InOut Labs. I have received a copy of Notice of Privacy Practices, as required by HIPAA from InOut Labs or I have chosen not to receive a copy.
- Some of our orders are processed by Rupa Health. I hereby consent to the Rupa Health Team ordering and handling lab work. Rupa Health can communicate with me via email regarding my health information.
I agree to take full financial responsibility for the cost of testing or services requested by me, and that payment is required prior to specimen collection or procedure.