HIPAA Privacy Authorization

  1.   I hereby authorize and direct the laboratory for Confirm Biosciences, Inc. to disclose to Confirm Biosciences, Inc. the results of my urine test for Gadolinium and any other substances that may appear in the test results.
  2.   This authorization for release of information covers all past, present and future periods. 
  3.   I hereby authorize Confirm Biosciences, Inc. and its laboratory to release any health records it may have regarding me to my representatives and their subsequent disclosure to others who may evaluate the results.
  4.   The medical information including, but not limited to, the results of my urine test for Gadolinium and other substances may be used by Confirm Biosciences, Inc. and its laboratory for all purposes.
  5.   This authorization shall be in force and effect for a period of five (5) years from the date of my signature below at which time this authorization shall expire.
  6.   I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and deliver it to Confirm Biosciences, Inc. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim.
  7.   I understand that health care treatment, payment or enrollment in a health plan will not be conditioned on whether I sign this authorization. However, Confirm Biosciences, Inc. and its laboratory will not perform the urine test and send the results to me unless this Authorization is signed by me. 8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may not be protected by federal or state law. If acceptable, please sign and return the original to Confirm Biosciences, Inc. A copy must be retained for your files.