Patient Authorization for Use and Disclosure of Protected Health InformationI understand and agree to the following statements:
- I am authorizing TestMeSTD.com to arrange testing for me for HIV, Hepatitis A, Hepatitis B, Hepatitis C, Herpes, Chlamydia, Gonorrhea, and/or Syphilis depending on the panel or tests selected.
- I am 18 years of age or older and I am the person being tested.
- I will provide a blood and/or urine sample at a Test Center.
- I understand that if I cancel my order I will be subject to a $50 cancellation fee that is non-refundable.
- I realize that TestMeSTD.com’s Test Packages do not test for every sexually transmitted disease.
- If my test results are positive, TestMeSTD.com may provide my personal information to my State’s Department of Public Health as required by individual state law. By law, they cannot compromise my confidentiality.
- I realize that the Test Packages and Tests that TestMeSTD.com arranges for me are highly sensitive; however there is a slight risk of a false positive or false negative result.
- I realize that TestMeSTD.com’s counselors do not provide medical advice or recommend treatment.
- I realize that TestMeSTD.com’s services are for screening purposes only and positive test results need to be followed up with a medical provider for appropriate treatment.
- I release and hold TestMeSTD.com harmless from any injury or personal damage that occurs while I am at a Test Center.
- I hereby authorize Medivo Services, LLC (with its affiliates, “Company”), applicable physicians, their staff and agents, and the laboratories that run medical tests for me to use and disclose health information about me in the manner and for the purposes stated below.
- This authorization applies to the use and disclosure of the following information about me: all information in laboratory requisition(s) submitted by me and the laboratory test values/results which are the result of the laboratory test(s) requested in the requisition.
- For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals, organizations and their representatives: (a) Health Testing Services, Inc. and its affiliates, their staff and agents, (b) Company and its affiliates, and their staff and agents, (c) the designated Company physician of record and its staff and agents, and (d) the applicable laboratory of record and its staff and agents, and as required by law.
- I understand that the Company 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 me may also be required before I receive my results.
- The information which is the subject of this authorization will be used or disclosed for the following purposes: (a) review and approve a laboratory requisition(s); and (b) review, process and deliver the laboratory test value(s)/result(s), and as necessary to comply with the state and federal laws. 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.
- This authorization evidences my informed decision to allow release of the information to the parties referenced in this authorization. This authorization is effective immediately and will expire one year after the date of this authorization.
- Upon my request, I may inspect or copy the information stated herein to be used or disclosed as provided in 42 CFR Sec. 164.524. I may refuse to sign this authorization in which case I will not be provided the services which I have chosen to purchase. Company and its designated physician of record may receive payment or other remuneration from a third party to (a) review and approve a laboratory requisition(s); and (b) review, process and deliver the laboratory test value(s)/result(s).
- I understand that I have a right to receive a copy of this authorization. I understand that the purpose of the laboratory test is to generate the results of the tests that I have voluntarily 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:
Medivo Services, LLC
55 Broad Street, 16th Floor
New York, New York 10004
By acknowledging this authorization electronically, I agree to its terms and representations.
Welcome to TestMeSTD.com, a company that assists consumers in obtaining laboratory tests (the “Service”) related to sexually transmitted diseases (“STDs”). TestMeSTD.com is not a laboratory, physician, or other healthcare provider. It does not directly provide healthcare, but rather assists consumers in contacting independent physicians and laboratories that will provide such care.
You understand that TestMeSTD.com will direct You to Medivo Services, LLC (“Medivo”) a national network of licensed and credentialed physicians, through a secure internet link. Medivo will provide a licensed and credentialed physician (“Physician”) to review all test requests and the laboratory results for any tests that are performed. Upon receiving your order, TestMeSTD.com will transmit your request to Medivo. Medivo will use the information you provide to create a laboratory requisition form, which you must take with you to a separate licensed laboratory in your service area (“Laboratory”) which will obtain blood and/or urine samples and perform the laboratory tests you have requested. The requisition form will contain a random number assigned to you by Medivo and will not contain your name or other identifying information about you. TestMeSTD.com will retain an email copy of your requisition form for its internal purposes. You authorize TestMeSTD.com to provide your healthcare information to Medivo and for TestMeSTD.com to retain the email copy of your requisition form. You also authorize the Laboratory to send the test results back to Medivo or a Physician. You further understand that TestMeSTD.com will not have or store any laboratory results.
No Provision of Healthcare Services
You agree to abide by all financial policies of TestMeSTD.com. You understand that if you cancel your order you will be subject to a $50 non-refundable cancellation fee.
Password Confidentiality and Computer Security
You are alone responsible for keeping Your password and personal verification code confidential and for the security of any computer You use to access the Service.
Your Obligation to Verify Information Sent to Your Healthcare Providers
You are solely responsible for all information stored or communicated using the Service, including any health information you may provide to physicians or laboratories introduced to you by TestMeSTD.com as part of the Service. You agree to verify the accuracy and completeness of all information communicated to Your physicians and other healthcare providers. You agree that We shall not be liable for any inaccuracy or incompleteness of any such information.
Copyright and Marks
All content on the Website is the copyrighted property of TestMeSTD.com. Other than the download to the User’s computer that is inherent in viewing a web page, Website contents may not be copied, reproduced, modified, published, uploaded, posted, transmitted, “framed” on another site, or distributed in any way without the prior written consent of TestMeSTD.com. User agrees not to sell, license, rent, modify, distribute, copy, reproduce, transmit, publicly display, publicly perform, publish, adapt, edit or create derivative works from materials or content available on the Website. You agree not to systematically retrieve data or other content or any materials from the Website for any reason, including but not limited to, to create or compile, directly or indirectly, a collection, compilation, database, directory or the like, whether by manual methods, through the use of "bots" or otherwise. Users must retain all copyright and other proprietary notices on any authorized reproductions of any portion of the Website. All TestMeSTD.com marks appearing on the Website belong solely and exclusively to PAI. Any third-party marks and content appearing on the Website are the property of their respective owners. Users are not permitted to use any of these marks or content without permission of the respective owner.
We may provide, or third parties may provide, links to other World Wide Websites or resources. Because we have no control over such sites and resources, You acknowledge and agree that We are not responsible for the availability of such external sites or resources, and do not endorse or recommend them. We are not responsible or liable for any content, advertising, products, or other materials on or available from such sites or resources. You further acknowledge and agree that We shall not be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with use of or reliance on any such content, goods or services available on or through any such site or resource. Any dealings among any User and any third parties mentioned on or found through the Website are solely between the User and the third parties, and are subject to any terms, conditions, warranties, or representations associated with those dealings.
TESTMESTD.COM MAKES NO WARRANTY, EITHER EXPRESSED OR IMPLIED, OF THE ACCURACY, MERCHANTABILITY, OR FITNESS FOR A PARTICULAR PURPOSE OF THE INFORMATION PROVIDED BY THIRD PARTIES. THIS INCLUDES, BUT IS NOT LIMITED TO, ANY INFORMATION FOUND ON A LINK LOCATED ON THIS WEBSITE THAT ALLOWS USERS TO ACCESS INFORMATION FOUND ON ANOTHER SITE. ADDITIONALLY, TESTMESTD.COM DOES NOT WARRANT THE EXISTENCE OR FUNCTIONALITY OF ANY SITE WHICH CAN BE ACCESSED THROUGH A LINK LOCATED ON THIS WEBSITE. IF YOU ACCESS ANY OF THIRD-PARTY WEBSITES LINKED TO THIS WEBSITE, YOU DO SO ENTIRELY AT YOUR OWN RISK.
Use of the Service and Software
No Unlawful or Prohibited Use
You expressly agree to refrain from doing, either personally or through an agent, any of the following:
a) Use any device or other means to harvest information about other Users.
b) Transmit, install, upload or otherwise transfer any virus or other item or process to the Website that in any way affects the use, enjoyment, or service of the Website.
c) Transmit, install, upload, or otherwise transfer any virus or other item to the Website that in any way affects the use, enjoyment or service of any User’s or TestMeSTD.com employee’s computer or other medium used to access the Website.
d) Modify the information, including headers, found on the Website.
e) Engage in any action which TestMeSTD.com determines is detrimental to the use and enjoyment of the Website.
f) Use the Website for any unlawful or defamatory means.
Users are prohibited from violating or attempting to violate the security of the Website. TestMeSTD.com will investigate occurrences of possible violations and will cooperate with all applicable law enforcement authorities in prosecuting violators.
Disclaimer & Limitation of Liability
Although TestMeSTD.com has attempted to provide accurate information on the Website, it makes no guarantee or warranty, express or implied, as to the reliability, accuracy, timeliness, or completeness of that information and assumes no responsibility for any errors or omissions in that information. USER ACCESSES THIS WEBSITE AT HIS OR HER OWN RISK. THE WEBSITE IS PROVIDED ON AN “AS IS, AS AVAILABLE” BASIS WITHOUT WARRANTY OF ANY KIND AND ANY AND ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR NON-INFRINGEMENT ARE SPECIFICALLY DISCLAIMED. NEITHER TestMeSTD.com NOR ITS AFFILIATES, EMPLOYEES, AGENTS, OR THIRD-PARTY CONTENT PROVIDERS SHALL BE LIABLE FOR ANY LOSS RESULTING FROM USE OR UNAVAILABILITY OF INFORMATION OR CONTENT ON THIS WEBSITE, INCLUDING BUT NOT LIMITED TO ANY LOST PROFITS, LOSS OR DAMAGE TO DATA, OR ANY DIRECT, INDIRECT, SPECIAL, CONSEQUENTIAL, COMPENSATORY, OR INCIDENTAL DAMAGES, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
NEITHER TestMeSTD.com NOR ANY OF ITS AFFILIATES, AGENTS, EMPLOYEES, OR ASSIGNS WARRANTS THE ACCURACY, ADEQUACY, OR COMPLETENESS OF THE INFORMATION ON THE WEBSITE AND EACH EXPRESSLY DISCLAIMS LIABILITY FOR ERRORS AND OMMISSIONS IN THE INFORMATION.
IN NO EVENT WILL TestMeSTD.com OR ANY OF ITS AFFILIATES, AGENTS, EMPLOYEES, OR ASSIGNS BE LIABLE FOR ANY DELAY, DIFFICULTY IN USE, COMPUTER VIRUSES, MALICIOUS CODE OR OTHER DEFECT IN THIS WEBSITE, ANY COMPATIBILITY BETWEEN THE WEBSITE AND THE USER’S FILES, AND THE USER’S BROWSER OR OTHER SITE ACCESSING PROGRAM.
THE PROVISIONS IN THIS PARAGRAPH ARE APPLICABLE TO ANY DAMAGE OR INJURY RESULTING FROM NEGLIGENCE OR OMISSION OF PAI, COMPUTER VIRUS OR OTHER SIMILAR ITEM, TELECOMMUNICATIONS ERRORS, OR UNAUTHORIZED ACCESS TO, OR USE OF, USER INFORMATION THROUGH THEFT OR ANY OTHER MEANS. USER AGREES THAT TestMeSTD.com IS NOT LIABLE FOR CRIMINAL, TORTIOUS, OR NEGLIGENT ACTIONS OR OMISSIONS OF THIRD PARTIES THAT AFFECT THIS WEBSITE.
USER AGREES NOT TO SEEK TO HOLD TestMeSTD.com OR ANY OF ITS AFFILIATES, AGENTS, EMPLOYEES, ASSIGNS, OR THIRD-PARTY CONTENT PROVIDERS LIABLE FOR ANY TORTIOUS OR ILLEGAL CONDUCT OF OTHER USERS.
USER AGREES NOT TO SEEK TO HOLD TestMeSTD.com OR ANY OF ITS AFFILIATES, AGENTS, EMPLOYEES, OR ASSIGNS LIABLE FOR ANY DAMAGE TO EQUIPMENT, HARDWARE, OR OTHER PROPERTY OF USER OR PERSONAL INJURY THAT ARISES IN CONNECTION WITH USE OF THE WEBSITE.
User understands and agrees that he or she is personally responsible for his or her behavior on this Website. User agrees to indemnify, defend, and hold harmless TestMeSTD.com, its directors, officers, employees, agents, and assigns from and against all losses, expenses, damages, costs (including, but not limited to, direct, incidental, consequential, exemplary, punitive, and direct damages), reasonable attorneys’ fees, resulting from or arising out of the User’s use, misuse, or inability to use the Website or any violation by the User of this Agreement and the provision of any medical care or laboratory tests provided by third parties, including third parties introduced to User or arranged for by TestMeSTD.com.
Term and Termination
General Legal Provisions.
Notices. If You have questions or comments regarding this Website, please contact Us at: firstname.lastname@example.org.
Compliance with Laws.TestMeSTD.com makes no representation that the content of the site is appropriate or available for use in all locations. Users are responsible for compliance with all applicable local laws.
TestMeSTD.com Services abides by all regulations as required by your state’s department of public health. TestMeSTD.com employs a national network of qualified physicians that prepare the test requisitions and review results. In the event of a denied test request, TestMeSTD.com will refund your fees in full. TestMeSTD.com services and materials are provided by TestMeSTD.com, solely owned by Health Testing Services Inc., and are for informational purposes only. The information provided is not a substitute for medical advice, diagnosis or treatment.
By acknowledging this authorization electronically, I agree to its terms and representations.CHDS01 609976v1