Lenco may be referred to in this Authorization as "we," "us," "our" and the like. Any parent, guardian or other legal representative executing this Authorization represents and warrants he/she has the appropriate legal representative authority to do so on behalf of the patient or minor. You are referred to herein as “you”, “I” or the like.
This Authorization applies to all Dates of Service (DOS) scheduled through the Lenco website/App and testing otherwise conducted by Lenco and communicated using the website/App.
Purpose of Release: Uses and Disclosures
I hereby authorize Lenco and its designees to access, disclose and release, as applicable, the following:
- We may store and transmit your appointment information and test results including to you and your ordering provider.
- We may share your Personal Information including Personal Health Information (PHI) with your physician or other clinician or provider to the extent either (1) you provide us with their contact information (using the name and contact information you provide or that they provide to us or update with us) and/or (2) they inform us of your patient status, to enable them to order and/or otherwise review testing and/or test results.
- We may use your Personal Information including Personal Health Information (PHI) for the purposes of insurance verification, determining eligibility, co-pay, deductible, co-insurance and/or cost-sharing obligations, and otherwise obtaining benefit plan information to use or share with your provider(s).
- We may share the Personal Information including Personal Health Information (PHI) with the insurance provider you identify to us, applicable plan administrator or their agent.
- We may contract vendors to handle the foregoing tasks for us.
I understand that the recipients of the information may benefit financially if I choose to utilize services through them.
Acceptance is Voluntary
I understand that signing this authorization is voluntary. My healthcare treatment and benefits (including payment rights and eligibility, as applicable) will not be affected if I do not sign this form. I am not required to use Lenco to schedule my testing. I understand that I may refuse to authorize the release of any personal or health information as described herein and that my refusal to sign and thereby consent to this release will prevent the disclosure of such information for such purposes, but will not affect the health care services I presently receive, or will receive, from third parties, though it may affect my ability to register with Lenco and/or use Lenco for testing or particular functionality within the website/App. I understand that I may get a copy of this form after I sign it.
I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, which may affect my ability to use Lenco or particular functionality within the website/App. If I do not revoke this authorization, it will expire when I de-activate my Lenco account in accordance with mechanisms made available on the Lenco website/App, and that re-activation may necessitate re-execution of this Authorization. This authorization may also be revoked at any time by notifying the Lenco Privacy Officer in writing at Lenco Diagnostic Laboratories, Inc., 1857 86th St, Brooklyn, NY 11214, or by e-mail at email@example.com. If I revoke this authorization, I understand that it will not have any effect on actions that the above-named recipients and other business associates, employees and/or professionals associated with them already took.
I understand that the information described, or some portion thereof, is protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I understand that by signing this authorization form, I authorize the disclosure and use of my protected health information as described above, and that this information may be re-disclosed if the recipient(s) described on this form are not required by law to protect the privacy of the information.
Nothing herein shall be deemed to prohibit, and LENCO DIAGNOSTIC LABORATORIES, INC. is hereby authorized, to use and exploit de-identified data and healthcare information derived by it from my use of the Lenco website and associated mobile app for any purpose, including for data aggregation, analysis, research, study and sale, and I have no rights in or to any proceeds relating thereto as such data and de-identified information belongs solely to LENCO DIAGNOSTIC LABORATORIES, INC. or its successor and assigns.
If we communicate your results to you in writing (by mail or electronically), know that, unless otherwise required by law: