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NCRCareOnline 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 NCRCareOnline website/App and testing otherwise conducted by NCRCareOnline and communicated using the website/App.
Purpose of Release: Uses and Disclosures
I hereby authorize NCRCareOnline and its designees to access, disclose and release, as applicable, the following:
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 NCRCareOnline 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 NCRCareOnline and/or use NCRCareOnline 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 NCRCareOnline or particular functionality within the website/App. If I do not revoke this authorization, it will expire when I de-activate my NCRCareOnline account in accordance with mechanisms made available on the NCRCareOnline 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 NCRCareOnline Privacy Officer in writing at NCRCareOnline, Inc., 178-11 union turnpike, Queens, NY 11366, or by e-mail at firstname.lastname@example.org. 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 NCRCareOnline, INC. is hereby authorized, to use and exploit de-identified data and healthcare information derived by it from my use of the NCRCareOnline 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 NCRCareOnline, INC. or its successor and assigns.
DISCLOSURE OF TEST RESULTS
If we communicate your results to you in writing (by mail or electronically), know that, unless otherwise required by law: