CHOOSE HEALTH CONSENT FOR SERVICES AND HIPAA PRIVACY AUTHORIZATION
Last modified: March 6, 2019See Below For Choose Health’s HIPAA PRIVACY AUTHORIZATION
Consent for Services
This consent form (“Consent”) reviews the benefits, risks and limitations of you, as the person who has created a Choose Health Account (referred to as “you” or “your”), utilizing the Services provided by Choose Health (the “Choose Health Services”). It also explains how your information and the biological sample(s) from the Choose Health Test Kit will be used.
Your Choose Health Test Kit will be shipped and your biological sample(s) will be processed only after you confirm that you have read and understood the contents of this form. By clicking on the box, you indicate that this Consent is a binding agreement and that you have read and understood the following terms. Capitalized terms used but not defined in this Consent have the meaning given to them in our other policies.
By clicking your acceptance, you have chosen to use the Choose Health Services and have given your informed consent to have your biological sample(s) tested for biomarkers. Biological samples shall consist solely of human fluids, depending on the test selected, that are intended to be analyzed for your sole use, and not for any other purpose other than to provide you information about how your body functions and to help you make more informed decisions and choices about your lifestyle and general wellbeing. You release Choose Health from any and all liability arising from the collection of t specimen, the laboratory analysis of such specimen, and the reporting of information concerning such analysis by
By clicking your acceptance, you understand that Choose Health and partner laboratories will have access to test results. Group statistics may be used for reporting and research purposes. No other individual or entity will have access to individual test results without prior authorization or as allowed by law. Certain laboratory results are required by state law to be reported to the State Department of Health. Partner laboratories will report such results to the applicable department of health, as required by law.
. You agree that Choose Health is not liable for the unauthorized release of your results or information unless such unauthorized release was the result of gross negligence or willful misconduct on the part of Choose Health.
Voluntary Participation and Withdrawal of Consent
The Choose Health Services are offered and available to users who are 18 years of age or older and are residents of the United States. Your use of the Choose Health Services is voluntary. It is your choice whether to utilize the Choose Health Services or not. Prior to accepting this Consent, you may wish to speak with your healthcare provider for further guidance about the Choose Health Services.
Depending on where you reside in the United States, certain test requests may need to be reviewed and approved by a licensed physician. Choose Health will not accept purchases from certain states, for regulatory reasons, and as outlined during the purchase process.
You may choose to withdraw your Consent or to stop using Choose Health's Services at any time. Such requests to should be sent to us by email at email@example.com
.Please note that while any changes you make will be reflected in our databases within a reasonable period of time, we may retain your information in the ordinary course of business, for the satisfaction of our legal obligations, or where we otherwise reasonably believe that we have a legitimate reason to do so. Information that has already been de-identified, anonymized, or aggregated may not be retrievable or traced back for destruction, deletion, or amendment.
Procedures and Protocol for Choose Health Test Kits
When you create your Account and purchase Choose Health Services, we will collect certain information from you. In order for the Choose Health Services to be provided as intended, you must provide accurate and correct information.
Through the Choose Health Services, you may purchase at-home testing kits (the “Test Kit”) with which you will collect biological samples (i.e. blood, saliva, or urine). This Test Kit will be provided to you by one of Choose Health’s designated accredited testing laboratory partners (“Accredited Lab”). Once you complete the Test Kit, you will mail it back to the Accredited Lab where your sample(s) will be tested for the biomarkers that you have selected and purchased. The Accredited Lab will test for the biomarkers that you have selected and purchased (including Cholesterol, Inflammation, and Glucose Levels).
Before mailing your completed Test Kit to the designated Accredited Lab, be sure to review the Test Kit directions carefully, provide any required information, and complete any included waivers, consents or authorizations. Failure to provide the required information, complete the tests as directed, or to execute the required documents may result in your sample(s) not being tested.
The results of your Test Kit(s) will be made available to you through Choose Health’s Website and Mobile Application. In the event we determine that a biological sample is not suitable for testing due to the content of the sample or because we believe the sample to have been submitted in violation of this Consent or the Choose Health Terms of Service
, we reserve the right to withhold the results and to not provide a refund.
Utilizing the Choose Health Services to discover what your biomarkers say about you can help you gain a better perspective on how your body functions. You may use this information to make more informed decisions and choices about your lifestyle and general wellbeing.
Risks In order to utilize the Choose Health Services, you must collect the appropriate biological sample(s) for the test(s). Some of our tests require a urine sample or a saliva sample; there are no risks associated with collecting urine or saliva samples using the containers provided in our test kit(s). Some of our tests require the collection of a blood sample. Although the risks and discomforts associated with a blood draw are very low, you might be at risk for excessive bleeding, fainting, feeling light-headed, bruising, hematoma (blood accumulating under the skin), or infection (a slight risk any time the skin is broken). If you have a history of excessive bleeding or fainting while having blood work done, we advise avoiding our tests that require self blood collection.
Disclosing certain information may make you uncomfortable. The Choose Health Services include biomarker tests that may reveal sensitive information about your body functions. For example, you may choose to share your test results with your licensed physician and as a result, you may learn about health conditions and problems or potential health risks that you were not aware of before you utilized the Choose Health Services. You may experience stress, anxiety, or emotional or physical discomfort when you learn about health problems or potential health problems. There may also be additional risks of utilizing the Choose Health Services that are currently unforeseeable.
OUR SERVICES DO NOT PROVIDE MEDICAL ADVICE. The information and content provided, including but not limited to text, graphics, images, videos, and other material contained in the Choose Health Services and on our Website and Mobile Application, are for informational purposes only and are not intended as a substitute for professional medical advice, help, diagnosis or treatment. For example, when you received your test results, you may for your convenience, receive test result ranges, for example, “low,” or “high.” You acknowledge that these result ranges do not constitute a diagnosis. Always seek the advice of your physician or other qualified healthcare provider with any questions you have regarding your medical care, and never disregard professional medical advice or delay seeking it because of something you have read on or via our Website or Mobile Application. Nothing contained in the Choose Health Services or on our Website or Mobile Application is intended to constitute a medical diagnosis or treatment. Reliance on any information appearing in the Choose Health Services or on our Website or Mobile Application, including but not limited to information provided by Choose Health or by other users of the Choose Health Services, is solely at your own risk. By clicking your acceptance, you understand and agree that your results are not intended to be used for any diagnostic purposes and are not a substitute for professional medical advice. You understand that the Choose Health Services are for information and educational use only; Choose Health does not provide medical services, diagnosis, treatment, or advice.
Choose Health does not warrant the accuracy, completeness, timeliness or usefulness of the opinions, content, services or other information provided through the Choose Health Services.
Choose Health and its affiliates, licensors, and suppliers have no control over and accept no responsibility for your compliance with the laws applicable to your state of residence.
Choose Health implements several safeguards to avoid technical errors, but as with all medical tests, there is a chance of a false positive or a false negative result. Some potential sources of error include sample mix-up, poor sample quality or contamination, and technical errors in the laboratory. Some biological factors, such as a history of bone marrow transplants or recent blood transfusions may limit the accuracy of the results or prevent the Choose Health Services from being completed.
Retention and Use of Your Information We are subject to multiple laws on the retention of data. Accordingly, we retain any information collected about you for as long as we are required to maintain it for regulatory and compliance purposes or for a legal or business necessity. You will send your biological sample(s) directly to our Accredited Lab that will conduct the test. Choose Health has no obligations or liability regarding the retention of your sample(s) by our Accredited Lab partners.
You understand that by providing any sample, having your sample processed, accessing your results, or providing information to us, you acquire no rights in any products or services that may be developed by Choose Health or its collaborating partners.
We may incorporate different or additional technologies to test or analyze data in the future. We may, at our sole discretion, choose to test or analyze your data using such technologies. We are not obligated to notify you if we chose to conduct different or additional testing or analysis on your data. Nor are we obligated to notify you if there is a new understanding of biomarkers that might result in a change to the interpretation of your results. We reserve the right to contact you, at our option, in the future. Your purchase of Choose Health Services does not automatically include any such different or additional technologies. You may have to pay additional fees in order to receive Choose Health Services using any future or additional technologies or features.
Withdrawal of Consent Your use of Choose Health’s services is voluntary. You may choose to withdraw your Consent or to stop using Choose Health’s services at any time. Such requests to should be sent to us by email at firstname.lastname@example.org, or in writing at Choose Health, 500 W 5th St, Suite 1105, Austin, Tx, 78701. Please note that while any changes you make will be reflected in our databases within a reasonable period of time, we may retain your information in the ordinary course of business, for the satisfaction of our legal obligations, or where we otherwise reasonably believe that we have a legitimate reason to do so. Information that has already been de-identified, anonymized, or aggregated may not be retrievable or traced back for destruction, deletion, or amendment.
Contacting Choose Health If you have questions or comments about the Choose Health Services or this Consent, please contact us by email at Info@choosehealth.io, or in writing at Choose Health, 500 W 5th St, Suite 1105, Austin, Tx, 78701.
______________HIPAA PRIVACY AUTHORIZATION
Purpose: This authorization allows our partner healthcare providers and laboratories to share your protected health information, including results of test(s) you order, with us.BY CLICKING ON THE “I HAVE READ AND ACCEPT THE HIPAA AUTHORIZATION” BUTTON ON THE ACCOUNT CREATION PAGE ON THE WWW.CHOOSEHEALTH.IO WEBSITE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS HIPAA PRIVACY AUTHORIZATION AND I HEREBY AUTHORIZE ALL TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH CHOOSE HEALTH (“ COMPANY”), 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 request(s) submitted by me or for me with my consent, andthe laboratory test values/results/information which are the result of such request(s).
I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees:
A. Company,B. applicable Accredited Labs, andC. Other Company partners for the purposes herein and as required or permitted by law.
This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, as permitted by law. I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization and understand that my refusal may affect the Choose Health Services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.
I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company at: Choose Health, 500 W 5th Street, Austin, Tx, 78701 or by email at Hello@ChooseHealth.io