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Physicians Wellness Network
By signing, I authorize Advanced Testing Center; Physicians Wellness Network to use and/or disclose certain protected health information about me to its physicians and its staff for review of results and tests ordered.
This authorization permits Advanced Testing Center; Physicians Wellness Network to use and/or disclose: the laboratory requisition submitted on my behalf, and; the laboratory test values which are the result of the laboratory test(s) requested in the requisition.
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 in the event laboratory values are outside of normal ranges, which require the physician or its agents to disclose test results to me. This protected health information is NEVER made public.
The purposes are provided so that I can make an informed decision whether to allow release of the information to Advanced Testing Center; Physicians Wellness Network. This authorization will expire one year after the submission of the laboratory requisition.
Physicians Wellness Network will receive payment or other remuneration from a third party in exchange for reviewing the protected health information.
I do not have to sign this authorization in order to have my laboratory test results reviewed by Physicians Wellness Network. In fact, I have the right to refuse to sign 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 except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:
Physicians Wellness Network
982 West Broadway
Post Office Box 15390
Jackson, WY 83002
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Signature of Patient or Legal Guardian Relationship to Patient
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Print Patient’s Name Date
Please sign and return via
Email: advancedtesting@charter.net
Fax: 309-213-6019
Mail: Advanced Testing Center
200 N Broadway, Ste. 130, Box 250
St. Louis, MO 63102
Patient/guardian must be provided with a signed copy of this authorization form. |
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