HIPPA Authorization for Use & Disclosure of Information
Completion of this document authorizes the disclosure and/or use of your individually identifiable health information as set forth below, consistent with federal and state law concerning the privacy of such information. This Authorization will allow Cosmos Health Solutions to receive your health care information from your COVID-19 laboratory test. Failure to provide all information requested may invalidate this Authorization.
USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize the use or disclosure of my health information as follows:
1. Persons/Organizations authorized to use and/or disclose the information:
* Cosmos Health Solutions, LLC
* Ark Clinical Research LLC
2. This Authorization applies to the following information:
All health information I disclose and that is created as part of my COVID-19 testing.
3. My health information will be used for the following purpose(s):
* Used for research collation only in anonymized form.
4. I may inspect or obtain a copy of the health information used or disclosed subject to this authorization. In addition, I have a right to receive a copy of this authorization.
5. No party will receive compensation for the use or disclosure of my information, except that Cosmos Health Solutions may pay the laboratory providing the COVID-19 testing a fee for the provision of the test.
6. California law prohibits Cosmos Health Solutions from making further disclosure of my health information unless Cosmos Health Solutions obtains another authorization from me or unless such disclosure is specifically required or permitted by law.
I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Cosmos Health Solutions: firstname.lastname@example.org. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this Authorization.
I acknowledge that I may receive a copy of this authorization upon request. I understand that I may inspect or obtain a copy of the health information used or disclosed subject to this authorization.